Achieving Clinical Success in Lingual Orthodontics

Achieving Clinical
Success in Lingual
Orthodontics
Julia Harfin
Augusto Urea
123
Achieving Clinical Success in Lingual
Orthodontics
Julia Harfin Augusto Urea
Achieving Clinical Success

in Lingual Orthodontics
Julia Harfin Augusto Urea
Department of Orthodontics Department of Orthodontics
Maimonides University Maimonides University
Buenos Aires Buenos Aires
Argentina Argentina
ISBN 978-3-319-06831-2 ISBN 978-3-319-06832-9 (eBook)

DOI 10.1007/978-3-319-06832-9
Springer Cham Heidelberg New York Dordrecht London
Library of Congress Control Number: 2014952676
Springer International Publishing Switzerland 2015

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To Luis whose unconditional support and dedication
made this possible.
To my daughters Viviana, Nora, and Adriana; to my
sons-in-law Gabriel (!), Javier, and Hugo; and to my
grandchildren Ari, Damian, Esteban, Nicolas, and
Emma for understanding the time that could not be
shared.
To my students that encouraged me to continue
teaching and to my professors for having given me
their knowledge and wisdom and for showing me that
study and hard work are the only way to fulfill our
dreams.
Julia Harfin
God, for blessing me once again ...

To my parents and brothers for their unconditional
support over the years.
To my students, for the constant feedback and
reciprocity in learning.
Dr. Harfin Julia, my mentor, for allowing me to travel
along this wonderful experience in Lingual Technique
for 24 years and share a passion for orthodontics.
To all working colleagues, for a world without
borders and to all who dare to cross them.... So
blessed!!
Augusto Urea
Preface
This book was written with the intention of helping and encouraging orthodontists
to use lingual appliances without recurring to expensive outside laboratories.
It provides detailed descriptions of procedures step by step, and it will enable
orthodontists the best results in a very simple and predictable manner.
Why lingual orthodontics?
In general, many adolescents and adults do not seek orthodontic treatment
because they do not like to use outside braces, even though they are aesthetic
(plastic, ceramic, zafiro, etc.).
Today, the lingual technique is a very successful approach to treat all types of
patients (children, adolescents, and adults), no matter what type of the initial maloc-
clusion or the amount of periodontal attachment.
After comparing all the aesthetic appliances, lingual orthodontics is the most
aesthetic and can be considered the truly invisible appliance (Poon 1998; Chatoo
2013).
Normally lingual patients make more aesthetic demands during the whole treat-
ment, but after a few months, when they observe the results, they are very collabora-
tive, and they highly recommend this treatment to their friends.
Although there is an adaptation period, the patients enthusiasm about the invis-
ible braces seems to help them to go through the first speech difficulties (Miyawaki
1999; Wiechmann 2008). After no more than 10 days, the patient can speak and eat
without any difficulties, and they strongly appreciate the improvement of their self-
image since they never consider using classic labial orthodontics at this age (Fillol
1997, 1998).
There is no need for special instruments when using the lingual technique, but
taking into account the reduced interbracket distance and the small dimension of the
brackets, it is easier to use angulated pliers.
Angled heads facilitate access to the lingual surfaces, especially at the bicuspid
and molar areas, and long handles improve visibility in the lateral zones.
Due to the variability of the lingual tooth anatomy and the difficulty in viewing
the palatal or lingual surfaces of the teeth, indirect bonding is mandatory. Careful
and precise indirect bonding allows total control of first- and third-order tooth
movement and also the torque that is more difficult to achieve due to the reduced
interbracket distance (Gorman and Smith 1991).
vii
viii Preface
The set-up laboratory procedure is one of the most reliable. The correct position
of the brackets is the cornerstone to achieve successful treatment outcomes.
A comprehensive understanding of lingual biomechanics is imperative to obtain-
ing successful results (Kurz 1998; Harfin and Urea 2010).
From the biomechanical point of view, one of the main differences between
labial and lingual brackets is the interbracket distance, which plays an important
role in relation to the amount of force exerted by the orthodontic wires. A small
reduction in the slot width can increase the elasticity of the wire, and, as a conse-
quence, lighter forces are used (Smith 1986; Kusy 2000).
It has been well established that dental plaque represents a risk factor in the pro-
gression of periodontal disease.
The installation of lingual orthodontic appliances increases the amount of palatal
and lingual plaque, which results in the formation of gingival hyperplasia and
pseudopockets.
Sometimes, this situation changes the subgingival ecosystem and facilitates the
inflammatory response of the periodontal tissues.
In order to control or avoid gingivo-periodontal problems, it is important to
inform the patient how he/she has to control it, and the orthodontist has to reinforce
oral hygiene at every appointment.
Also, root resorption is not higher when using lingual appliances.
It is important that the periodontal status of every patient should be evaluated
before treatment begins and periodically during the whole orthodontic treatment.
In combination with an accurate diagnosis and treatment planning, it is ideal to
use a bracket-wire system that gives us the possibility of reducing force and friction,
improving rotation control, obtaining easier sliding mechanics, lowering patient
discomfort, and reducing chair and treatment time.
It is possible to achieve the same high standard in the finishing stages as when
labial brackets are used. -
Buenos Aires, Argentina Julia Harfin

Buenos Aires, Argentina Augusto Urea
Bibliography
Chatoo A. A view from behind: a history of lingual orthodontics. J Orthod Suppl. 2013;51:S27.
Fillol D. Improving patient comfort with lingual brackets. J Clin Orthod. 1997;31:68994.
Fillol D. The resurgence of lingual orthodontics. Clin Impression. 1998;7:29.
Gorman JC, Smith RJ. Comparison of treatment effects with labial and lingual fixed appliances.
Am J Orthod Dentofacial Orthop. 1991;99:2029.
Harfin J, Urea A. Ortodoncia Lingual: procedimientos y aplicacin clinica. Buenos Aires:
Editorial Mdica Panamericana; 2010.
Kurz C, Romano R. Lingual orthodontics: historical perspective. In: Romano R, editor. Lingual
Orthodontics. Hamilton: BC Decker; 1998. p. 320.
Kusy RP. Ongoing innovations in biomechanics and materials for the new millenium. Angle
Orthod. 2000;70:36676.
Preface ix
Miyawaki S, Yasuhara M, Koh Y. Disconfort caused by bonded lingual orthodontic appliances in

adult patients as examined by retrospective questionnaire. Am J Orthod Dentofacial Orthop.
1999;115:838.
Poon KC, Taverne AA. Lingual orthodontics: a review of its history. Aust Orthod J.
1998;15:1014.
Smith JR. Gorman JC, Kurz C, Dunn RM. Keys to success in lingual therapy. J Clin Orthod.
1986;20:25261.
Wiechmann D, Gerb J, Stamm T, Hohoff A. Prediction of oral discomfort and dysfunction in lin-
gual orthodontics. A preliminary report. Am J Orthod Dentofacial Orthop. 2008;133:35964.
Contents
1 Biomechanics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
How to Take the Silicone Impression . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Laboratory Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Indirect Bonding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Methods of Ligation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Phase I . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
Lingual Utility Arch. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
Use of Quad Helix in Lingual Orthodontics . . . . . . . . . . . . . . . . . . . . . . . 19
Partial Canine Retraction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
Use of Coil Springs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
How to Correct Rotated Teeth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
Phase II. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
Anchorage Control . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
Use of Elastics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37
Tips on How to Reposition a Lingual Bracket. . . . . . . . . . . . . . . . . . . . . . 40
Transverse Control of the Position of the Upper First Molars. . . . . . . . . . 44
Phase III . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
Bibliography . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
2 Treatment of the Lower Anterior Crowding
by Stripping Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
Case Study 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48
Case Study 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51
Case Study 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56
Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57
Bibliography . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58
3 Deep Overbite. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59
Case Study 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60
Case Study 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68
Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73
Bibliography . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73
xi
xii Contents
4 Efficient Treatment of Open Bite in Nongrowing Patients. . . . . . . . . . 75

Case Study 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76
Case Study 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79
Case Study 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87
Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97
Bibliography . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 98
5 Use of Pendulum with Lingual Appliances . . . . . . . . . . . . . . . . . . . . . . 99
Case Study 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 101
Case Study 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 109
Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 117
Bibliography . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 117
6 Impacted Canines. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 119
Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 130
Bibliography . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 131
7 Clinical Cases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 133
Case Study 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 134
Case Study 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 143
Case Study 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 152
Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 163
Bibliography . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 163
8 Finishing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 165
Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 172
Bibliography . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 173
9 Summary and Outlook . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 175
Bibliography . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 177
Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 179
Biomechanics
1
From the biomechanical point of view, lingual orthodontic treatment has important
differences in comparison to labial orthodontic treatment.
The interbracket distance is reduced, and the forces are directed from the lingual
surface of the anterior teeth to the center of resistance of the same teeth. For this reason,
the use of TMA archwires that has greater resilience is highly recommendable because
its stiffness is in between nickel-titanium and stainless steel wires. TMA wires allow
the incorporation of any type of loops for retraction or protraction forces and also mini-
mize the reaction on the last molars when the retraction loops are activated.
This is a very important item that is sometimes not taken into account by clini-
cians. The adhesion of the brackets to the lingual and palatal surfaces of the teeth
requires careful preparation.
Some patients have deep grooves not only near the cingulum of the central, lat-
eral incisors and canines but also on the palatal surfaces of the 1st and 2nd molars.
That is why sealing them before taking the impressions is advisable.
Also, the normalization of the palatal marginal rims is important. Occasionally,
their shape and size dont allow brackets to adapt correctly.
Gingival tissues also need to be normalized since inflammation caused by gingi-
vitis can alter the proper position of the brackets. Working with a periodontist
before, during, and after the treatment is necessary.
How to Take the Silicone Impression
Before impressions are taken, careful hygiene of the teeth has to be performed by
the orthodontist in order to eliminate all the biofilm.
A two-phase technique silicone impression is recommendable to take an accu-
rate one. The impression tray has to be rigid and nondeformable. The adhesion of
the impression material to the impression tray is a crucial phase in which errors
must be avoided.
Springer International Publishing Switzerland 2015 1

J. Harfin, A. Urea, Achieving Clinical Success in Lingual Orthodontics,
DOI 10.1007/978-3-319-06832-9_1
2 1 Biomechanics
Mix uniformly into homogeneous state before use (Fig. 1.1a, b).
a b
Fig. 1.1 (a, b) Mixing the impression material putty with the catalyst
It should be correctly extended on the tray in order to obtain a good surface

detail.
Incorporating mostly all anatomical landmarks is required to create an ideal
impression (Fig. 1.2a, b).
a b
Fig. 1.2 (a, b) Impression material extended on the tray and mouth impression
For the second phase, regular body silicone impression material is suggested.
Mix the two components (base and catalyst) in a gentle way for fullfilled the first
impression, following the indications of each silicone brand (Fig. 1.3a, b).
a b
Fig. 1.3 (a, b) Pre- and post-second-phase silicone impression

Laboratory Procedures 3
It is highly recommended to disinfect the silicone impression after taking it and

to follow the manufacturers instructions of your choice, and for best results, wait
for 30 min before casting the impression, knowing that the impression remains
dimensionally stable for a minimum of 7 days and a maximum of 14 days.
Laboratory Procedures
It is generally accepted by orthodontists that the indirect technique is the best option
when lingual brackets are used. Several methods with different systems have been
described during the last 25 years.
In this section, vital information on how to achieve excellent results with in-
office indirect method will be described step by step.
No expensive outside laboratories will be needed and consistent results will be
seen.
A careful setup has to be made taking into account the patients diagnosis, prog-
nosis, and treatment plan.
When silicone is used, the impressions have to be taken in two stages for a better
definition. It is important to control the definition of the impression in order to check
for the absence of bubbles and the precise contour of the teeth (Fig. 1.4a).
The second step is to mark the center of each tooth to determine the exact posi-
tion of each dowel pin (Fig. 1.4b).
In patients with mild or severe crowding, it is recommendable to perform two
cast models, to maintain the correct anatomy of the mesial and distal margins of
each crowded tooth.
To avoid fractures during the laboratory process, extra-hard plaster or densita
gypsum rock is suggested.
a b
Fig. 1.4 (a, b) Silicone impression have to be taken in two stages and with the dowel pins in place
4 1 Biomechanics
To obtain the best copy of the teeth, it is better to make two plaster models,
inserting the dowel pins sorting one tooth from another (Fig. 1.5a, b).
a b
Fig. 1.5 (a, b) Two plaster models to obtain a better setup with dowel pins in place
A perfect copy of the teeth can be obtained with this method (Fig. 1.6a, b).
a b
Fig. 1.6 (a, b) Models with densita gypsum rock

After the vertical cut of the plaster, stump of each tooth should be stripped with
a steel or tungsten dental bur, slenderizing the stone while carefully preserving the
mesial-distal dimension of each tooth without removing the dental gingival limit
(Fig. 1.7a, b).
a b
Fig. 1.7 (a, b) How to cut and prepare each tooth for the setup cast model
After reshaping and numbering each tooth, they have to be put in place in the
original silicone impression, and then a horseshoe dental wax has to cover all the
dowel pins (Fig. 1.8a, b).
a b
Fig. 1.8 (a, b) Dowel pins placed in each tooth and covered with dental wax
6 1 Biomechanics
The next step is to remove the dental wax with all the teeth fully covered with it
(Fig. 1.9a, b).
a b
Fig. 1.9 (a, b) Initial malocclusion model may be identical from the original
The following step is to prepare a solid base with stone gypsum to avoid any
undesirable teeth movement (Fig. 1.10a).
It is essential to remember that all the teeth have to be numbered to avoid any
undesirable position mistakes (Fig. 1.10b).
a b
Fig. 1.10 (a, b) Initial malocclusion with numbered teeth
Lateral views to control de occlusal plane (Fig. 1.11a, b).
a b
Fig. 1.11 (a, b) Numbered teeth in the lateral views

The next step is to straighten the teeth according to the previous diagnosis and
treatment plan. To assess dental leveling, the amount of overbite, overjet, and curve
of Spee presented in the initial malocclusion should be taken into account. The
model has to be placed in hot water to facilitate the alignment of the plaster cast
teeth (Fig. 1.12a, b).
a b
Fig. 1.12 (a, b) Softened wax in warm water to easily maneuver the teeth
The teeth have to be slightly moved to their final position, straightening the teeth
and checking the contact points between them, and rotations of the premolars and
molars have to be fulfilled (Fig. 1.13a, b).
a b
Fig. 1.13 (a, b) Final alignment

8 1 Biomechanics
In order to achieve a more ideal and individual patient tooth alignment according
to the previous diagnosis and treatment plan, an ideal chart plate can be helpful
(Fig. 1.14a, b).
a b
Fig. 1.14 (a, b) Ideal lingual chart plate
After that, a silicone spray (any brand) should be placed to facilitate the bracket
debonding (Fig. 1.15a, b).
a b
Fig. 1.15 (a, b) Silicone spray application
The model should be poured to prepare a key plaster to avoid undesirable incli-
nations when the brackets and the wire are bonded to the cast model (Fig. 1.16a, b).
a b
Fig. 1.16 (a, b) Vestibular plaster contention

The following step is to insert the brackets into a 0.017 0.025 TMA archwire.
A ligature tying plier is very useful at this point (Fig. 1.17a, b).
a b
Fig. 1.17 (a, b) Bracket inserts with elastomeric ligatures
The distocanine and mesiomolar bends have to be done after all the brackets are
inserted in the 0.017 0.025 TMA wire (Fig. 1.18a, b).
a b
Fig. 1.18 (a, b) For better control, a tweed plier is recommended
The measure of the distal canine bend is related to the width differences between
the cuspids and first premolars in every patient. Sometimes it could be different
between the right and left sides. It is advisable to control the wire torque to maintain
the same occlusal plane (Fig. 1.19a, b).
a b
Fig. 1.19 (a, b) Upper archwire before and after disto-canine bend
10 1 Biomechanics
After all the bends are performed, the archwire has to be stabilized in the setup
with acrylic keys (Fig. 1.20a, b).
a b
Fig. 1.20 (a, b) Acrylic distal keys in place
If the diagnosis requires extra anterior torque and before the lingual brackets are
placed on the cast model, the orthodontist can manage it with an easy and controlled
method. Extratorque labial anterior brackets (Ricketts brackets technique) are
placed on the labial surface of the six anterior upper teeth with a rectangular
0.16 0.22 Ni-Ti wire (Fig. 1.21a, b).
a b
Fig. 1.21 (a, b) Ricketts brackets with a 0.016 0.022 Ni-Ti sectional wire in place
The comparison between the initial and post arch expression of the torque is
clearly visible (Fig. 1.22a, b).
a b
Fig. 1.22 (a, b) Pre- and post-extra anterior torque
The extra torque effect can be observed and is highly recommended for extrac-
tion cases and Class II Div II deep overbite patients (Fig. 1.23a, b).
a b
Fig. 1.23 (a, b) Occlusal view of the pre- and post-extra anterior torque
It is widely accepted that a correct setup is the only way to achieve not only the
ideal bracket positioning but also successful treatment outcomes. If the setup is not
totally controlled, it is impossible to achieve excellent and consistent results.
Most problems can be avoided by monitoring every step.
12 1 Biomechanics
Indirect Bonding
Indirect method is highly recommended due to the great difference in the palatal
and lingual tooth anatomy. It must be easy to make, permit accurate bonding, have
control of the possible failures, easy to rebond when it is necessary, and have high
precision and reduced cost.
The first step is to clean the enamel surface using a pumice paste with a rubber
cup or a polishing brush (Fig. 1.24a, b).
a b
Fig. 1.24 (a, b) A low-speed handpiece with a cleansing brush is recommended
The second step is to rinse with water to remove any pumice paste and to dry
thoroughly with oil-free air.
Cheek, lip, and tongue retractors are very helpful to maintain a completely dry
field during all the bonding process (Fig. 1.25).
Fig. 1.25 Cheek, lip, and

tongue retractors
Indirect Bonding 13
Thirty-seven percent phosphoric acid gel for about 30 is used for enamel condi-
tioning. Acid gel provides more control on the surface to be etched. Since the enamel
surface must not be contaminated with saliva, a wet gauze to remove the acid gel is
recommended (Fig. 1.26a, b).
a b
Fig. 1.26 (a, b) Before and after the plication of 37 % phosphoric acid gel
Then the enamel surface has to be dried very carefully until it acquires a frosty
white appearance. In almost all patients, no micro-etching is necessary (Fig. 1.27a, b).
a b
Fig. 1.27 (a, b) A dry air syringe is useful to obtain a frosty enamel surface
After this, a small amount of primer is applied to the tooth and to the bracket base
at the same time.
Light-curing primer with filling microparticles is highly recommendable in order to
diminish enamel decalcifications or carious lesions under the brackets (Fig. 1.28a, b).
a b
Fig. 1.28 (a, b) Light-cure bonding agent adhesive in place

14 1 Biomechanics
It is important that all the excess adhesive is carefully removed to improve oral
hygiene and less gingival inflammation or decalcification around the bracket.
It is preferred to start transferring individual caps from the last molar to midline
avoiding unnecessary contamination risks (Fig. 1.29a, b).
a b
Fig. 1.29 (a, b) Molar transferring cap in place
The cap can be easily removed with a thin dental explorer instrument from occlu-
sal to gingival (Fig. 1.30a, b).
a b
Fig. 1.30 (a, b) Easy method to remove the individual transfer cap
Methods of Ligation 15
Methods of Ligation
There are different ligation approaches in lingual orthodontics that use stainless
steel or elastomeric ligatures.
The use of esthetic ligatures is highly recommendable since their visibility was
improved in the upper and lower arches. The flexibility of the esthetic ligature
ALLOWS better manipulation, twist, cut, and tuck under the archwire.
The double-tie ligature allows the full insertion of the archwire into the bracket
slot avoiding the archwire to slip off the bracket.
First, the ligature has to be placed behind the wire and the bracket in order to
embrace and insert the wire at the end of the bracket slot (Fig. 1.31a, b).
a b
Fig. 1.31 (a, b) How to place the ligature wire behind the archwire and the bracket
Cross ligature around the bracket and pull up the ends in order to twist them on
the side of the bracket (Fig. 1.32a, b).
a b
Fig. 1.32 (a, b) After the ligature wire crosses the bracket, the ends have to be twisted around them
16 1 Biomechanics
With a cutting plier, loose ends should be cut and pressed behind the bracket, pre-
venting any discomfort for patients. A ligature director or a Mathieu plier is helpful.
It is important that the excess wire is cut after twisting the ligature under the
bracket (Fig. 1.33a, b).
a b
Fig. 1.33 (a, b) After twisting the ligature, the excess wire has to be cut
Phase I
Phase I always includes the alignment and leveling of the maxillary and mandibular
arches.
In general, low load deflection arches are used as initial alignment wire depend-
ing on the amount of discrepancy, initial malocclusion, and treatment objectives.
To initiate Phase I, it is important to bear in mind that since the interbracket dis-
tance is narrower than in labial orthodontics, the suggested sequence is either coax-
ial archwire (0.0155 or 0.0175), Ni-Ti archwire (0.010 or 0.013), or Ni-Ti-Cu
(0.016) (Fig. 1.34a, b).
a b
Fig. 1.34 (a, b) Initial photograph and with a 0-013 Ni-Ti archwire
Lingual Utility Arch 17
When all the slots are aligned, a 0.016 TMA or 0.016 SS archwire is recom-
mendable to finish Phase I (Fig. 1.35a, b).
a b
Fig. 1.35 (a, b) After the alignment was completed, a TMA 0.0175 0.0175 was suggested
until the retention was placed
From the biological point of view, it is important to emphasize that the first
archwire used must be very resilient to ensure very light forces at the beginning
of the treatment. It is advisable that this archwire remains for a minimum period
of 612 weeks.
Lingual Utility Arch
The intrusion of lower incisors is a real challenge not only in adolescents but in
adults too. The use of a lingual utility arch is highly recommendable and easy to
manage.
It is fabricated with 0.016 0.016 blue Elgiloy wire which is the same as used
in labial orthodontics, described by Ricketts many years ago. An activation with 15
tip back bends mesial to the first molar is advisable (Fig. 1.36a, b).
a b
Fig. 1.36 (a, b) Lower lingual utility arches

18 1 Biomechanics
The importance of the utility arch is that it gives us the possibility to intrude the
lower incisors in a very easy and controllable manner (Fig. 1.37a, b).
a b
Fig. 1.37 (a, b) Lower utility arch in place
In order to keep premolar and cuspids aligned, a sectional wire 0.016 SS should
be placed including the 2nd molar in order to maintain the lateral alignment
(Fig. 1.38a, b).
a b
Fig. 1.38 (a, b) Sectional 0.016 wires to keep cuspids and bicuspids aligned
Lateral views with the two sectional and utility arches in place, before activation
(Fig. 1.39a, b).
a b
Fig. 1.39 (a, b) The two arches are clearly visible

Use of Quad Helix in Lingual Orthodontics 19
The comparison before and after the activation shows the action of the utility
arch. The amount of intrusion could be decided according to the treatment plan
(Fig. 1.40a, b).
a b
Fig. 1.40 (a, b) Before and after the activation of the utility arch
Use of Quad Helix in Lingual Orthodontics
When mild orthodontic expansion is needed, the use of the quad-helix appliance is
very recommendable, especially in adult patients.
This appliance was first developed by Dr. Herbst and popularized by Dr. Ricketts,
and it is used for symmetrical or asymmetrical expansion of the maxillary dental
arch. Normally, it is made with 0.036 SS or TMA wire and welded to the 1st molar
bands. If a removable one is decided on, it is possible to attach it to palatal tubes.
Two months after the results are achieved, it can be removed and the brackets
have to be placed on the same day in order to avoid losing the results achieved.
This is a clear example that shows the benefits of the use of a quad helix in a
34-year-old patient with a narrow maxilla, before extractions were done. A 46-
week activation was suggested (Fig. 1.41a, b).
a b
Fig. 1.41 (a, b) Pretreatment occlusal photograph, with the quad helix in place
20 1 Biomechanics
In this particular patient after three activations, the quad helix was replaced for a
transpalatal arch, and then upper bicuspid extractions were performed.
Sliding mechanics was recommended for the retraction of the anterior teeth.
At the end of the treatment, a fixed retention wire (0.0195) was suggested.
The improvement of the transverse dimension was clearly visible (Fig. 1.42a, b).
a b
Fig. 1.42 (a, b) During and after extraction sliding mechanics
Partial Canine Retraction
In patients with moderate or severe crowding or when canines have to move distally
in conjunction to maximum anchorage, an individualized arch has to be designed to
move only the canine distally.
The arch (SS 0.014 or TMA 0.016) has a small round loop just in front of the
bicuspid. An elastomeric chain is placed from the canine to the loop to move it dis-
tally (Fig. 1.43).
Fig. 1.43 Partial canine

retraction arch
The following patient is a clear example.

The chief complaint of the patient was midline deviation. The upper first right
bicuspid had been extracted when she was a child during her first orthodontic treat-
ment. The extraction of the upper left first bicuspid was recommended in order to
correct the midline.
Partial Canine Retraction 21
It is preferable to normalize the position of the left upper canine before the dis-
talization of the incisors (Fig. 1.44a, b).
a b
Fig. 1.44 (a, b) Partial retraction canine arch at the beginning and 3 months after
When the canine was in the desired position, the treatment was completed with
standard biomechanics. Round and rectangular (0.016 or 0.0175 0.0175) arches
are always suggested (Fig. 1.45a, b).
a b
Fig. 1.45 (a, b) Six and nine months in treatment

22 1 Biomechanics
The results showed the normalization of the midline and the complete closure of
the extraction space. A fixed retention wire was placed the same day the brackets
were removed (Fig. 1.46a, b).
a b
Fig. 1.46 (a, b) Last rectangular arch (TMA 0.0175 x = .0175) and retention wire at the end of
the treatment
Use of Coil Springs
The use of coil springs is based on the same criteria as used in the labial technique.
Nickel-titanium open coil springs are recommendable because they release low
and continuous forces in comparison to stainless steel coil springs.
Its activation has to be smaller since the interbracket distance is shorter.
More control is necessary in adult patients with reduced periodontal attachment
to avoid undesirable rotations that take a lot of time and effort to recover.
A 45-year-old patient with a severe lack of space in the anterior region came to
the office for a non-extraction treatment. It was preferable to start gaining the space
for the right upper incisor and after that for the canine. Ni-Ti open coil spring in
conjunction with a 0.016 TMA wire was recommended (Fig. 1.47a, b).
a b
Fig. 1.47 (a, b) Use of Ni-Ti coil spring to gain space for the upper right canine and central
incisor
Use of Coil Springs 23
When the space was recovered, a 0.0175 0.0175 TMA for torque control was
suggested. At the end of the treatment, a fixed retention wire from the right first
bicuspid to the left first bicuspid was placed for a long period of time (Fig. 1.48a, b).
a b
Fig. 1.48 (a, b) A 0.0175 0.0175 TMA for alignment and torque expression and with the fixed
retention wire in place
The same procedure can be used in the lower arch.

This patient had a lack of space for his lower lateral incisor. As always, Ni-Ti
open coil spring is preferable because a more continuous and controlled force was
released.
When the space was recovered, the bracket on the lateral incisor was bonded
with indirect method as usual (Fig. 1.49a, b).
a b
Fig. 1.49 (a, b) Lower arch with the Ni-Ti coil spring in place
24 1 Biomechanics
After realignment and leveling the lower arch, a rectangular wire (0.0175 0.1|75
TMA) was placed. As always, a fixed retention wire is recommended (Fig. 1.50a, b)
from first right lower bicuspid to the left one.
a b
Fig. 1.50 (a, b) Final archwire for torque control and retention wire bonded
How to Correct Rotated Teeth
The correction of rotated teeth is not always easy to manage. The short interbracket
distance in conjunction with the small width of the lingual bracket increases the dif-
ficulties in correcting them.
Three techniques can be used: cemented bracket with composite compensation,
Scott ligature, or coupled effect.
Before even thinking about biomechanics, the necessary space has to be made
before the correction of a rotated tooth begins.
When the patient has a mild rotation, a full engagement of a round Ni-Ti-Cu
archwire with a double over-tie ligature is advisable.
If small rotation is present, some rotation bend in the TMA 0.016 archwire is
recommendable, but the most predictable method is the Scott ligature in patients
with mild to severe rotations.
She is a 34-year-old patient whose right lower lateral incisor was disto-rotated.
Because of the lack of space, a Ni-Ti coil spring was used for 2 months
(Fig. 1.51a, b).
a b
Fig. 1.51 (a, b) Use of the Ni-Ti coil spring for gaining space in order to bond the lingual bracket
on the lower lateral right incisor
How to Correct Rotated Teeth 25
After the space was achieved, the use of a Scott ligature was recommendable.
A piece of an elastomeric chain was placed using an explorer in order to tie in the
knot around the wire.
The elastomer link was threaded through the other end over the archwire
(Fig. 1.52a, b).
a b
Fig. 1.52 (a, b) Elastomeric chain to initiate the Scott ligature
Since the mesial side of the lateral lower incisor is lingualized, the knot has to be
placed on the opposite side of the movement that is needed to be achieved.
After that, the elastic chain has to be placed under the distal contact point of the
lateral incisor and has to embrace the labial surface to the mesial side in order to
reach the bracket hook (Fig. 1.53a, b).
a b
Fig. 1.53 (a, b) A Mathieu plier is useful to perform this ligature

26 1 Biomechanics
At Fig. 1.54a, the couple effect is activated: A labial point of flowable restorative
material may be useful in order to maintain the elastomeric segment on the labial
surface in place (Fig. 1.54b).
a b
Fig. 1.54 (a, b) Labial view of the esthetic elastomeric chain with the labial flow composite for
its stabilization
Two months later, the normalization of the incisor is evident. For some patients,
the elastomeric chain ligature has to be changed for esthetic reasons, every
23 weeks (Fig. 1.55a, b).
a b
Fig. 1.55 (a, b) The lower lateral incisor was fully corrected
How to Correct Rotated Teeth 27
The same procedure has to be done to correct a rotated tooth in the maxilla.
The chief complaint of this patient is the rotation of the upper right lateral incisor
due to a relapse of a previous orthodontic treatment. The most controllable proce-
dure is the same method used in the Scott ligature as was described in the lower
incisor rotation discussed in the previous patient (Fig. 1.56a, b).
a b
Fig. 1.56 (a, b) A section of an esthetic ligature chain to rotate the upper right lateral incisor
As was described before, it is necessary to have the correct amount of space to

normalize the position of the tooth (Fig. 1.57a, b).
a b
Fig. 1.57 (a, b) Initial steps of the Scott ligature

28 1 Biomechanics
To facilitate the normalization of the rotated tooth, the elastic chain has to be placed
under the distal contact point of the lateral incisor and has to embrace the labial sur-
face to the mesial side in order to reach the palatal bracket hook (Fig. 1.58a, b).
Clear elastic chain is recommendable for esthetic reasons.
a b
Fig. 1.58 (a, b) Passing the elastomeric chain on the distal contact point
The rotation was fully completed after 4 weeks (Fig. 1.59a, b).
The gingival tissues were completely normal as well as the papillae.
a b
Fig. 1.59 (a, b) After 4 weeks, the upper lateral incisor was normalized
Taking into account that the rotated teeth have a great percentage of relapse, it is
important that the final rectangular arch (0.0175 0.0175) for torque expression
has to be in place at least 4 months (Fig. 1.60a, b).
a b
Fig. 1.60 (a, b) Final and fixed retention wire in place

Phase II 29
This procedure is very predictable and easy to manage with less risk of collateral
damage of the adjacent teeth.
No overcorrection is promoted in lingual orthodontics nor circumferential supra-
crestal fiberotomy techniques.
As there is no scientific evidence that determines the best protocol to maintain
the correction of the rotated tooth, a long-term fixed retention is recommended.
Phase II
Anchorage Control
Anchorage control is one of the most important chapters in orthodontic

biomechanics.
It is possible to classify it into three groups: minimum, reciprocal, and maximum
anchorage.
For lingual orthodontic treatment, an effective control is necessary with the help
of some auxiliary appliances.
The use of a Nance button with a transpalatal bar (TPA) is very useful in cases
when maximum anchorage is required. It has to be placed 1 or 2 weeks before the
extractions are done. Ideally, it should be cemented with glass ionomer cement as
the liberation of fluoride is very helpful in the prevention of caries.
The following example demonstrates the use of this appliance with en masse
retraction and sliding mechanics (Fig. 1.61a, b).
a b
Fig. 1.61 (a, b) Nance button with transpalatal bar in place before and during retraction
procedure
30 1 Biomechanics
The inclusion of the second molars in the posterior anchorage unit is very
useful, too.
The same design is used when the extraction of the second bicuspids is recom-
mended. In these cases, it is preferable to retract the first premolar and then the
anterior segment as a group (Fig. 1.62a, b).
a b
Fig. 1.62 (a, b) Before and after the sectional distalization of the first bicuspids
The use of micro-implants as a noncompliance method is very advisable in

patients when maximum anchorage is required (Kyung 2006).
For anatomic reasons, the best place for them to be implanted is between the 1st
and 2nd molars or between the 2nd bicuspid and the first molar.
Two different approaches are shown in the following pictures. In the left one, a
direct anchorage between the molars and the micro-implant was selected, and in the
other one, the microimplant was used directly for en masse retraction of the anterior
region.
One of the most important advantages of the use of this type of micro-implants
is that they provide absolute anchorage without the cooperation of the patient in
conjunction with a controlled retraction mechanics and less lateral bowing effect
(Fig. 1.63a, b).
a b
Fig. 1.63 (a, b) Micro-implants used as maximum anchorage

Phase II 31
They provide very simple and predictable results with no patient cooperation.
They can be placed at the hard palate, maxillary molar region, mandibular retromo-
lar area, or anterior zone. Since they are not osseointegrated, they are easy to place
and to remove.
To achieve predictable results, it is important to have knowledge of biomechan-
ics to design a precise force system and to recognize the anatomical structures to
find the correct insertion sites and angulation.
Microimplants are available in different lengths and diameters with several head
shapes. The orthodontist has the possibility to select the most appropriate one
according to the initial malocclusion, age of the patient, amount of periodontal
attachment, and anchorage objectives. Forces can be applied immediately after
insertion, but some orthodontists recommend waiting 710 days.
Another method to enhance anchorage is to bond a fixed retention wire on the
labial side of the second bicuspid, first and second molars. It is easy and comfort-
able for the patient and for the orthodontist, and it can be used on the upper and
lower arch (Fig. 1.64a, b).
a b
Fig. 1.64 (a, b) Upper and lower labial retention wires for anchorage reinforcement
When extractions are indicated, the initial malocclusion and facial and muscular
biotype must be taken into consideration during the diagnosis process and treatment
objectives for individualized treatment.
This would lead us to choose the best method for space closure needed to reduce
friction, bowing effect, and torque loss. Sliding mechanics and retraction en masse
are the most suitable choices.
It is important to increase the reverse curve in the retraction arches every time the
patient comes to the office.
It is important to manage the anterior torque before, during, and after the space
closure. Otherwise, vertical bowing effects can occur.
To normalize anterior flared incisors, a 0.016 or a 0.0175 0.0175 TMA arch
is recommendable before the closing of the extraction spaces begins.
The common wire for expressing torque in lingual technique is 0.0175 0.0175;
after that, a 0.016 0.022 SS should be in place maintaining the torque prior to
retruding the anterior segment, when 0.018 slots are used.
32 1 Biomechanics
As was suggested before, it is necessary to add 510 of positive torque to the

incisors to anticipate the loss of anterior torque due to bowing effect (Fig. 1.65a, b).
a b
Fig. 1.65 (a, b) Posterior occlusal plane alignment and torque expression
This is a clear example of torque loss during the retrusion of the anterior teeth
due to bowing effect causes (Fig. 1.66a, b).
a b
Fig. 1.66 (a, b) Loss of anterior torque
Transversal bowing effect is the consequence when molars move lingually

during space closure.
A 0.016 0.022 SS wire with the reverse curve in the anterior and transversal
plane to avoid bowing effect is suggested.
In extraction cases, it is necessary not to place insets between the bicuspid and
molar to facilitate the activation (Fig. 1.67a, b).
Transversal constriction effect should be expected during space closure.
a b
Fig. 1.67 (a, b) Reverse curves expressed in a SS 0.016 0.022 archwire.

Phase II 33
It is advisable to align lingual posterior segments (severe Class II Div I) before

extractions are performed to enhance the anchorage unit and reduce friction when
the anterior segment is retruded.
Ni-Ti-Cu 0.016 0.022 is good for the alignment of these segments allowing
better occlusion in the posterior sites (Fig. 1.68a, b).
a b
Fig. 1.68 (a, b) Different examples of pre-extraction posterior alignment are shown
When it is necessary to improve the transversal width, the canines have to be

included in the sectional arches.
Normally, 34 months are required to achieve the posterior alignment. During
that time, it is advisable to start the leveling of the lower arch to enhance posterior
occlusion (Fig. 1.69a, b).
a b
Fig. 1.69 (a, b) Posterior lateral sectional alignment
In severe Class II Div I with a significant overjet (more than 6 mm), the extrac-
tions have to be performed before the brackets are placed on the incisors. This is the
best method to avoid undesirable contact points between the lower incisors and the
brackets on the upper incisors.
34 1 Biomechanics
When the anterior upper segment has to be retruded using sliding mechanics
with an elastic chain from the cuspids to the second molars, the tipping of the cus-
pids root presented an undesirable inclination to the labial side and some fenestra-
tion could be appear.
To avoid this inconvenience, the retraction from a hook between the lateral inci-
sor and the cuspid was advisable.
Bearing in mind that upper lateral incisors have a more fragile root than the cen-
trals, a direct elastic chain to the lateral bracket should be avoided to diminish root
resorption. An elastic chain tied from the power hook to the second molar should be
performed in sliding mechanics.
Two removable power hooks are placed in the SS 0.016 0.022 between the
upper lateral incisors and the cuspids. An elastic chain from those hooks to the sec-
ond upper molars would retrude the anterior segment. Activation every 46 weeks
is recommendable (Fig. 1.70a, b).
a b
Fig. 1.70 (a, b) A SS 0.016 0.022 with hooks for sliding mechanics retraction
When the sliding retraction 0.016 0.022 SS wire is in place, overtie elastomeric
elastics have to insert the wire into the bracket slot and tightened firmly (Fig. 1.71a, b).
a b
Fig. 1.71 (a, b) A Mathieu thin-end plier is highly recommended

Phase II 35
After the wire is completely tight and inserted in brackets and molar tubes, an
figure-of-eight ligature has to be extended from canine to canine, consolidating the
anterior segment (Fig. 1.72a, b).
a b
Fig. 1.72 (a, b) Activated elastic chains from the lateral hooks to molars are in place
When en masse retraction is proposed, different types of loop figures could be

used: a T loop, omega, or any horizontal closed loop.
It is important to remember that the retraction of the anterior teeth should not be
performed with round wires. An extra torque on the incisors is suggested before the
omega loop is activated.
The omega loop has good acceptance for the patient with no harmful conse-
quence to the gingival tissues. It is very easy to construct and allows proper oral
hygiene for the patient.
The following photos described how to perform an omega loop en masse
retraction arch with a 0.016 0.022 SS archwire step by step.
Mark point the middle and distal cuspid inset mark, and with an Angle 139 plier,
the wire has to be bent to perform the cuspid distal inset (Fig. 1.73a, b).
a b
Fig. 1.73 (a, b) Angle N 139 plier is useful to perform the loop
36 1 Biomechanics
The second bend is performed 1 mm down the first one with the same plier.
After that, in order to construct the omega loop in 0.022, surface is necessary to
twist the archwire to maintain the 0.016 surface as in the initial anterior segment of
the arch (Fig. 1.74a, b).
a b
Fig. 1.74 (a, b) Two tweed arch-adjusting pliers are needed to twist the wire
To continue the omega loop, the same plier on the round side is used to complete
the loop. The height of the omega loop should be measured on the patient palatal
premises (Fig. 1.75a, b).
a b
Fig. 1.75 (a, b) Final design of the omega loop
The torque difference is clearly observed in the closer angle maintaining the
0.016 0.022 in the same horizontal plane (Fig. 1.76a, b).
a b
Fig. 1.76 (a, b) Closer view of the omega loop

Use of Elastics 37
All the closing arches with or without loops have to include the transversal and
sagittal reverse curves to prevent torque loss, prevent incisor extrusion, and control
the bowing effect (Fig. 1.77a, b).
a b
Fig. 1.77 (a, b) Omega loop arch with reverse curves for en masse retraction
This is an example of an extraction case with the omega loop activated from
distal of the second molar in conjunction with a figure-of-eight ligature wire
from cuspid to cuspid. One millimeter of activation every 46 weeks is highly
recommendable (Fig. 1.78a, b).
a b
Fig. 1.78 (a, b) Activation of the omega loop for in masse retraction
Use of Elastics
Elastic chains and rubber bands are widely used in combination with lingual brack-
ets to correct sagittal, transversal, and vertical discrepancies.
The main advantages are low cost and they are easy to use.
The protocol of using intermaxillary elastics is similar to those used in labial
orthodontics, but we have to take into account the position of the lingual bracket
hooks to determine the correct direction of the forces in the three planes or space
orientation.
It is recommendable to use it at least 16 h a day to reach treatment goals.
Failure to wear rubber bands can result in a longer than expected treatment time.
38 1 Biomechanics
The periodontal biotype and the amount of periodontal attachment play an

important role, especially in adult patients.
Since vertical elastics tend to decrease the inclination discrepancy and to com-
press the arch width, it is advisable to control it every 23 weeks.
They have to be used with rectangular wires to avoid unnecessary inclinations,
undesirable extrusions, and transversal compressions in the arch width.
When it is necessary, labial esthetic buttons are recommended.
The following examples describe the most common and different alternatives.
When the molars are in a crossbite relation, an elastic between the palatal hook
of the 1st upper molar tube and an esthetic button on the labial surface of the 1st
lower molar is advisable (1/8 medium or heavy) (Fig. 1.79a, b).
a b
Fig. 1.79 (a, b) Crisscross elastics to normalize the position of the first molars
Also, 1/8 medium or heavy elastics can be used to achieve Class I canine occlusion
in the vertical direction (Fig. 1.80a, b).
a b
Fig. 1.80 (a, b) Front and lateral photographs of Class III elastics (1/8 heavy)
Use of Elastics 39
To improve lateral occlusion and cuspid guidance, triangular elastics can be used
with labial esthetic buttons (1/8 medium or heavy) (Fig. 1.81a, b).
a b
Fig. 1.81 (a, b) Triangular elastics to improve lateral occlusion
To overcorrect anterior open bite, inverted triangular elastics are recommended

(1/8 medium or heavy) (Fig. 1.82a, b).
a b
Fig. 1.82 (a, b) Triangular anterior elastics to correct anterior open bite
To correct midline deviation, 3/16 elastics (medium) are suggested (Fig. 1.83a, b).
a b
Fig. 1.83 (a, b) Elastics to correct midline deviation

40 1 Biomechanics
To normalize the anteroposterior relation, the use of Class II elastics is helpful (

medium or heavy) (Fig. 1.84a, b).
a b
Fig. 1.84 (a, b) Class II elastics to improve canine and molar relationship
Tips on How to Reposition a Lingual Bracket
One of the most common issues you can encounter during the treatment process is
when brackets come off and repositioning them is necessary.
The most simple and safe way is to make an individual cap again.
This procedure can be done by an assistant or by the orthodontist in the office,
using the original setup and the custom-made arch that was made before. It takes
only a few minutes to make it and the procedure is very reliable.
The following example describes the clinical procedure step by step.
Each cap has to be individualized and identified for each corresponding tooth
(Fig. 1.85a, b).
a b
Fig. 1.85 (a, b) Individual silicone transfer cap

Tips on How to Reposition a Lingual Bracket 41
The first step is to clean the tooth carefully with pumice without fluoride.
All the remnant adhesive has to be removed thoroughly (Fig. 1.86a, b).
a b
Fig. 1.86 (a, b) Preparation of the palatal enamel surface
To avoid failures during the adhesive process, the gingival tissues need to be
healthy; otherwise, bleeding could affect adhesion.
Then rinse with water while using a high-speed evacuation system and dry the
tooth with an air syringe (Fig. 1.87a, b).
a b
Fig. 1.87 (a, b) Cleaning with pumice powder to polish the tooth
It is recommendable to apply the etching gel carefully to the bonding surfaces

with an applicator sponge. After 30 the acid gel has to be removed very gently with
another sponge, and then rinsing and drying the palatal surface with dry air is
advisable.
The etched enamel must now have a frosty appearance.
42 1 Biomechanics
It is important that the patient maintain the surface dry without contact with
saliva or any other liquid (Fig. 1.88a, b).
a b
Fig. 1.88 (a, b) Before and after etching the palatal surface
It is necessary to place the primer or sealant on the tooth and on the bracket at the
same time. Although the bonding resin is applied on the bracket base and on the
tooth surface at the same time, the gap may not be completely filled with resin and
as a consequence decalcifications or cavities under the bracket could appear
(Fig. 1.89a, b).
a b
Fig. 1.89 (a, b) The bonding agent has to be placed on the palatal surface and on the bracket at
the same time
Tips on How to Reposition a Lingual Bracket 43
Then place the cap with the bracket onto the tooth immediately after dispens-
ing the sealant. During adhesion, it is very important to press the cap against the
lingual and labial sides of the tooth firmly before and during the curing process
(Fig. 1.90a, b).
a b
Fig. 1.90 (a, b) Cap in place with the dental curing light
When the adhesion process is finished, taking off the cap is easy. The cap should
only be used once and must be discarded after removing it (Fig. 1.91a, b).
a b
Fig. 1.91 (a, b) Removing the cap carefully

44 1 Biomechanics
Transverse Control of the Position of the Upper First Molars
Correct positioning of the molars in the transverse dimension is important to achieve

functional occlusion and long-term stability.
A simplified and easy to construct lingual arch used to correct the palatal posi-
tion of the upper molars will be presented.
A 0.0175 0.0175 TMA or 0.016 0.016 blue Elgiloy wire is recommended.
The mesio-molar bend was designed keeping the correction of the molar in mind,
with an activation every 4 or 6 weeks.
This patient was a clear example. The left first molar was in crossbite position.
An individualized 0.0175 0.0175 archwire was designed to correct its palatal
position (Fig. 1.92a, b).
a b
Fig. 1.92 (a, b) Occlusal pretreatment photograph and a 0.0175 0.0175 individualized archwire
After 2 months with a 0.013 Ni-Ti wire for leveling and alignment, a
0.016 0.016 Elgiloy wire with this design was placed. Four months later, the
normalization of the molar was achieved (Fig. 1.93a, b).
a b
Fig. 1.93 (a, b) Before and after 4 months with STB brackets in place
Bibliography 45
This is a very reliable and easy way to normalize the position of the molar with-
out the use of crisscross elastics.
Phase III
Most orthodontic cases require some adjustment of individual tooth position to

align and level marginal ridges, the gingival margin, or in-out position.
It is important to remember that all the little but important discrepancies can
appear in this stage even though the laboratory procedures for indirect bonding have
been well executed.
The narrow interbracket distance often complicates loop bending, particularly
between the lower anterior teeth.
When all the treatment objectives are achieved, it is recommendable that the finish-
ing arch was maintained in place for 1012 weeks to achieve optimal tooth position.
A fixed retention wire is advisable in all types of malocclusions for a long period
of time. It has to be placed the same day the brackets are removed.
Conclusion
For achieving excellent and consistent results, indirect bonding is highly
recommendable.
There is no standard archwire sequence and ideal arch form for all patients alike.
An individualized archwire is mandatory.
Torque control on the anterior segment plays an important role in the success
of the treatment. It is very important to control torque before beginning to close
the extraction spaces.
A comprehensive understanding of the force systems in lingual orthodontics
is imperative for obtaining successful results.
Bibliography
Alexander CM, Alexander RG, Gorman J, et al. Lingual orthodontics: a status report. Part 5
Lingual mechanotherapy. J Clin Orthod. 1983;17:99115.
Fujita K. New orthodontic treatment with lingual brackets and mushroom archwire technique. Am
J Orthod. 1979;76:65775.
Geron S, Vardimon AD. Six anchorage keys in lingual orthodontic sliding mechanics. World J
Orthod. 2003;4:25865.
Geron S, Shpack N, Kandos S, Davidovitch M. Anchorage los, a multifactorial response. Angle
Orthod. 2003;5:7307.
Gibert A. In-house lingual bracket transfer systems I. In: Romano R, editor. Lingual and esthetic
orthodontics. London: Quintessence; 2011. p. 25574.
Higgins DW. Indirect bonding with light-cured adhesive and a hybrid transfer tray. Semin Orthod.
2007;13:648.
46 1 Biomechanics
Hiro T, Takemoto K. Resin core indirect bonding system-improvement of lingual orthodontic

treatment. J Jpn Orthod Soc. 1998;57:8391.
Hiro T. Indirect bonded technique in lingual orthodontics: the Hiro system. In: Romano R, editor.
Lingual and esthetic orthodontics. Japan: Quintessence; 2011. p. 23954.
Komori A, Fujisawa M, Iguchi S. Common base for precise direct bonding of lingual orthodontic
brackets. Int Orthod. 2010;8:1427.
Kyung HM, Kim BC, Sung JH. The effect of resin base thickness on shear bonding strength in
lingual tooth surface. J Clin Orthod. 2002;36:3208.
Kyung HM. The use of microimplants in lingual orthodontic treatment. Semin Orthod.
2006;12:18690.
Lee JS, Park HS, Kyung HM. Micro-implant anchorage for lingual treatment of a skeletal Class II
malocclusion. J Clin Orthod. 2001;35:6437.
Moran KI. Relative wire stiffness due to lingual versus labial interbracket distance. Am J Orthod
Dentofacial Orthop. 1987;92:2432.
Prieto MGL, Ishikawa EN, Prieto LT. A groove guided indirect transfer system for lingual brack-
ets. J Clin Orthod. 2007;41:3726.
Romano R. Lingual orthodontics. London/Hamilton: BC Decaer; 1998.
Scuzzo G, Takemoto. Invisible orthodontics: current concepts and solutions. In: Lingual orthodon-
tics. Chicago Il: Quintessence; 2003
Scuzzo G, Takemoto K. Lingual orthodontics: a new approach using STB light lingual system and
lingual straight wire. Chicago: Quintessence; 2010.
Segner D, Ibe D. Light wire lingual orthodontics: biomechanical considerations. In: Scuzzo G,
Takemoto K, editors. Lingual orthodontics: a new approach using STB light lingual system.
Berlin: Quintessence; 2010. p. 2837.
Takemoto K. Anchorage control in lingual orthodontics. In: Romano R, editor. Lingual orthodon-
tics. Hamilton: BC Decker; 1998. p. 7582.
Weichman D, Rummel V, Thaileim A, Simon JS, Weichman L. Customized brackets and arch-
wires for lingual orthodontic treatment. Am J Orthod Dentofacial Orthop. 2003;124:5939.
Treatment of the Lower Anterior
Crowding by Stripping Procedures 2
Lower anterior crowding is a problem that affects nearly 80 % of the adult

population.
It is accepted that it is greatly due to the diminishing of the arch length as a result
of aging.
It can be seen in Class I, II, or III patients no matter the facial biotype or whether
they were treated orthodontically or not.
Regarding etiology, it can be classified into three groups: primary, secondary, or
as a consequence of relapse.
The primary group is the result of a negative relation between the teeth width and
the arch length.
If it appears later in life, it could be related to parafunctional habits, loss of verti-
cal posterior dimension, or occlusal problems, and these patients are in the second-
ary group. Some studies show that there is no close relationship among the shape of
the inferior incisors, the irregularity index, or the lower anterior crowding.
It is important to take into account not only the degree of the crowding but also
the rate of progression during the last years. If the progression is high, it is necessary
to check if posterior occlusal contacts are present.
Little et al. (1988) as well as Bishara et al. (1996) observed that there are no
specific variables that could determine when and to what extent relapse could occur
in patients treated with or without extractions.
When the crowding is less than 5 mm, stripping or mesiodistal enamel reduction
is the best choice. Considerations should be similar to those when labial brackets
are used. This procedure was described for the first time in 1944 by Ballard and then
was popularized by Dr. Bjorn Zachrisson (Zachrisson 2005; Zachrisson et al. 2007).
Shillingburg and Grace, in 1973, established the amount of enamel that could be
removed from each anterior tooth (mesial and distal sides), and Sheridan (Sheridan
1987; Sheridan and Hastings 1992) promoted stripping in the lateral areas.
Stripping is never performed before brackets are placed since the space gained
could be easily lost. The shape of the anterior teeth is important; those with a trian-
gular shape make it easier to perform stripping.

DOI 10.1007/978-3-319-06832-9_2
48 2 Treatment of the Lower Anterior Crowding by Stripping Procedures
Bjorn Zachrisson (Zachrisson 2005; Zachrisson et al. 2007) demonstrated that it

is recommendable to begin on teeth that are better positioned in order to avoid
unnecessary stripping or steps that are very difficult to correct.
The authors recommend the use of diamond single-side strips because a better
control is achieved. The use of burs or disks could produce more and unfavorable
loss of enamel.
Before enamel reduction is performed, it is important to take intraoral radio-
graphs to determine the thickness of the enamel and the position of the roots in
relation to the inter-radicular bone.
The amount of enamel that must be removed from each side of the tooth by strip-
ping is only 0.250.50 mm in total, and the dentin will not be exposed, of course.
The total maximum amount of stripping recommended is 4 mm in the upper anterior
teeth and 3 mm for the mandibular incisors.
After it, a careful polishing of the stripped areas is highly recommended in addi-
tion to daily fluoride rinses (Radlanski 1988).
It is important to remember that this procedure can be performed if the patients
have good oral hygiene. Otherwise, interproximal cavities will be the result in a
very short period of time.
At the end of the treatment, a fixed bonded retainer is advisable and should also
be controlled every 6 months, for a long period of time.
Stripping is contraindicated in patients with rectangular-shaped teeth, hypopla-
sia, or hypersensitivity.
The following cases will demonstrate these principles.
Case Study 1
A 26-year-old female patient visited the clinic complaining about anterior lower
crowding. She had had a 3-year orthodontic treatment and two first upper bicuspid
extractions (Fig. 2.1a, b).
a b
Fig. 2.1 (a, b) Pretreatment front and lower occlusal photographs

Case Study 1 49
No retention appliance was indicated at that time.

Gingival margin, overjet, and overbite were pretty normal.
The molar relationship was Class I canine and molar on the right and Class II on
left side. The upper incisors were slightly retroinclined.
Good oral hygiene was present (Fig. 2.2a, b).
a b
Fig. 2.2 (a, b) Lateral photographs at the beginning of the treatment
Mandibular arch discrepancy was 3 mm.

The treatment objective was to correct the anterior crowding without extractions
using interproximal enamel reduction (Fig. 2.3a, b).
No brackets were placed in the maxilla.
a b
Fig. 2.3 (a, b) Upper and lower arches before treatment

The goal of the treatment was to correct the lower anterior crowding without any
extraction.
Lingual brackets were indirectly bonded with a setup technique.
After the initial alignment phase with a 0.0155 coaxial arch, a Ni-Ti archwire
0.014 was placed. Two months later, stripping between the lower incisors was
progressively performed during eight visits (8 months) (Fig. 2.4a, b).
a b
Fig. 2.4 (a, b) Before and after lower anterior stripping
These are the diamond single-side strips and the composite polishing strips that
were recommended by the authors (Fig. 2.5a, b).
a b
Fig. 2.5 (a, b) Different types of diamond and polishing strips

Case Study 2 51
The final arch was a 0.0175 0.0175 TMA archwire for 3 months, and after
that, the patient was ready for debonding.
It is important to remember that the fixed retention wire has to be placed the
same day the brackets are removed (Fig. 2.6a, b).
The original mild crowding was corrected and the overbite was improved.
At the end of the treatment, the patient showed no signs of gingival inflamma-
tion, the midlines were coincident, and the papillae were totally recovered.
a b
Fig. 2.6 (a, b) Final front photograph and lower fixed retention in place
Case Study 2
This patient came to the office for a second opinion regarding the lower anterior
crowding. No TMJ problems or medical diseases were present but his oral hygiene
was poor.
The front photographs showed a mild overbite and uneven lower gingival line,
and the midlines were coincident (Fig. 2.7a, b).
a b
Fig. 2.7 (a, b) Pretreatment front and overbite photographs. Midlines were coincident
Class I canine and molar were present on the right and left side (Fig. 2.8a, b) in
conjunction with some retroinclination of the lower incisors.
a b
Fig. 2.8 (a, b) Class I molar and canine were observed at the beginning of the treatment
The maxillary arch exhibited some constriction on the lateral sides, and 5 mm of
discrepancy was visible in the lower arch (Fig. 2.9a, b). The right upper first molar
was mesio-rotated.
a b
Fig. 2.9 (a, b) Upper and lower arches before treatment

Case Study 2 53
Treatment Objectives
1. Align and level the arches.
2. Maintain Class I canine and molar.
3. Normalize lower anterior crowding.
4. Improve oral hygiene.
5. Improve overjet and overbite.
6. Maintain long-term mandibular retention.
To achieve these objectives, lingual brackets with bite planes were placed in the
maxilla and in the mandible with a coaxial 0.015 during the beginning of the align-
ment (7th Generation lingual brackets Ormco Corporation) (Fig. 2.10a, b).
a b
Fig. 2.10 (a, b) 7th Generation lingual brackets with bite plane were bonded indirectly in the
upper and lower arches
After 4 months, a 0.017 0.017 TMA arch was placed in the upper arch for a
better torque control, and monthly stripping on the lower incisors was performed in
conjunction with a 0.016 TMA archwire (Fig. 2.11a, b).
The oral hygiene and the gingival tissues improved.
a b
Fig. 2.11 (a, b) Results after 4 months of treatment with monthly lower anterior stripping
The lower anterior incisors were effectively aligned only with enamel interproxi-
mal reduction. A 0.016 stainless steel wire was used in order to complete the nor-
malization of the position of the lower teeth (Fig. 2.12a, b).
a b
Fig. 2.12 (a, b) Upper and lower arches at the end of the 1st phase of treatment
Front photographs at the end of the treatment. The normalization of the overbite,
overjet, and lower anterior crowding was achieved. The midlines were coincident
and the oral hygiene improved. The result of stripping resulted in better shape of the
teeth and additional stability for the realignment (Fig. 2.13a, b).
a b
Fig. 2.13 (a, b) Post-treatment front photographs

Case Study 2 55
On the lateral views, Class I canine and molar were maintained. The occlusal
plane and the gingival margin were normalized (Fig. 2.14a, b).
a b
Fig. 2.14 (a, b) Lateral views at the end of the treatment
Fixed upper and lower retainers were placed the same day the brackets were
removed (Fig. 2.15a, b). Long-term use was recommended, especially in the man-
dibular anterior arch.
a b
Fig. 2.15 (a, b) Upper and lower arches with the retention wire in place
Control 3 years later. The results were maintained or even improved.

The stripping procedure resulted not only in an improvement in the shape of the
teeth but also in the stability of the results. The gingival tissues were well main-
tained, and the interdental papillae were totally normal (Fig. 2.16a, b).
a b
Fig. 2.16 (a, b) Control 3 years post-treatment
Case Study 3
Where the upper arch is concerned, the results could be obtained as well. This is the
problem with this 65-year-old patient with 4 mm of discrepancy in the upper arch.
Lingual brackets with bite plane were indirectly bonded with a low load deflec-
tion arch to begin alignment and leveling (0.0175 Respond) (Fig. 2.17a, b).
After some enamel reduction between the upper bicuspids, an elastic chain to
normalize the rotation of the right and left bicuspids was placed between the first
bicuspid and the first molar.
a b
Fig. 2.17 (a, b) Upper arch pretreatment and during the alignment procedure with 7th Generation
brackets
Case Study 3 57
To achieve good torque control, a 0.0175 0.0175 TMA archwire was sug-
gested for 4 months (Fig. 2.18a, b). As always, a fixed retention wire was bonded
between the right and left cuspids for a long-term period.
a b
Fig. 2.18 (a, b) Before and after a 0.0175 0.0175 TMA archwire for better torque control
Conclusion
Mesiodistal enamel reduction or stripping is a safe and controlled technique that
allows us to have better occlusion with good contact point relationships and to resolve
mild crowding without extractions (Radlanski et al. 1989; Zhong et al. 2000).
It is a common procedure in orthodontics during the adult orthodontic treat-
ment and can be used with labial or lingual brackets, but it is not recommendable
for children or adolescents (Romano 1998; Harfin 2000).
It is important to take into account some principles to achieve positive long-
term results. The first one is that it is necessary to calculate the exact amount of
enamel that has to be reduced and never to begin the stripping procedures before
brackets are placed (Gilmore and Little 1984; Puneky et al. 1984).
It is important to remember that stripping has to be initiated at the mesial and
distal sides of straight teeth and never reduce rotated teeth first.
The use of gingival and labial protection helps the orthodontist to avoid irre-
versible damage to the soft or hard tissues (Fillol 1993). Some remineralization
is expected after the stripping procedures as was described by El-Mangoury et al.
(1991).
Long-term evaluation of periodontal and occlusal results confirms that this is
a safe and reliable method to normalize mild anterior inferior crowding.
There are no specific methods to reduce the possibility of relapse.
In a long-term period, overcorrection or circumferential supracrestal fiberot-
omy is not totally reliable to avoid relapse.
Bibliography
Bishara SE, Treer JE, Damon P, Olsen M. Changes in the dental arches and dentition between 25
and 45 years of age. Angle Orthod. 1996;66:41722.
El-Mangoury NH, Moussa NM, Mostafa YA. In vitro remineralization after air rotor stripping.
J Clin Orthod. 1991;25:758.
Fillol D. Apport de la sculpture amlaire interproximale a lorthodontie de ladulte (troiseme par-
tie). Rev Orthop Dento Faciale. 1993;27:35367.
Gilmore CA, Little RM. Mandibular incisor dimensions and crowding. Am J Orthod.
1984;86:493502.
Harfin J. Interpoximal stripping for the treatment of adult crowding. J Clin Orthod.
2000;34:42433.
Little RM, Riedel RA, Artun J. An evaluation of changes in mandibular anterior alignment from
1020 years post retention. Am J Orthod Dentofacial Orthop. 1988;93:1238.
Puneky PJ, Sadowsky C, BeGole EA. Tooth morphology and lower incisor alignment many years
after orthodontic therapy. Am J Orthod. 1984;86:299305.
Radlanski RJ, Ralph R, Jager A, Zimmer B. Plaque accumulation caused by interdental stripping.
Radlanski RJ, Ralph R, Jager A, Zimmer B. Morphology of interdentally stripped enamel one year
after treatment. J Clin Orthod. 1989;23:74850.
Romano R. Interproximal enamel reduction in lingual orthodontics. In: Lingual orthodontics.
Hamilton: B.C.Decker Inc; 1998. p. 97107.
Sheridan JJ. Air -rotor stripping update. J Clin Orthod. 1987;21:7818.
Sheridan JJ, Hastings J. Air rotor stripping and lower incisor extraction treatment. J Clin Orthod.
1992;26:1822.
Zachrisson BU. Actual damage to teeth and periodontal tissues with mesiodental enamel reduc-
tion. World J Orthod. 2005;5:17883.
Zachrisson BU, Nyoygaard L, Mobarak K. Dental health assessed more than 10 years after inter-
proximal enamel reduction of mandibular anterior teeth. Am J Orthod Dentofacial Orthop.
2007;131:1629.
Zhong M, Jost-Brickmann PG, Zelman M, Zelman S, Radlanski RJ. Clinical evaluation of a new
technique for interdental enamel reduction. J Orofac Orthop. 2000;61:4329.
Deep Overbite
3
Deep overbite is one of the most common and difficult malocclusions to treat and
maintain stability in adult patients. It may be present with or without other dental
problems. Its prevalence is 58 % in our population.
A very deep bite may result in damage to the soft palatal tissues and abnormal
wear of the lower front teeth or on the palatal surfaces of the anterior upper incisors
causing tooth sensitivity or pain.
It is fundamental to understand its etiology since it varies from patient to patient.
Skeletal or dental deep bite are caused by genetic, environmental factors, or a com-
bination of both (Geron and Vardimon 2003; Geron et al. 2004).
Exaggerated curve of Spee, abrasion, loss of posterior teeth, overeruption and
retroinclination of the upper incisors, short mandibular ramus, short lower facial
third, decreased gonial angle, etc. are the most common features.
The anterior facial height, chin position, amount of exposure of the maxillary
and mandibular anterior teeth at rest and during function, and amount of gingival
display are relevant factors to be considered in the treatment planning.
It can be corrected by extrusion of the upper or lower posterior teeth, intrusion of
the upper or lower incisors, or a combination of both.
The treatment protocol differs if the posterior vertical dimension is lost or not
and if a remnant growth spur is present or not.
Avoiding excessive extrusion of the maxillary molars and leveling occlusal plane
would allow better control of the vertical changes. When extrusion of the lower inci-
sors is present, lingual intrusive force is applied more closely to the center of resis-
tance of the lower incisors producing their intrusion with little flaring.
Unfortunately, there is no specific cephalogram to determine the best plan of
treatment.
Treating this malocclusion using lingual brackets with bite plane has many
advantages. The temporary open bite at the anterior region provides a slight open
bite on the bicuspids and molars that allows the leveling of the occlusal plane
(Forsberg and Hellsing 1984; Magnus and Hellsing 1984; Carano 2008).

DOI 10.1007/978-3-319-06832-9_3
60 3 Deep Overbite
The discomfort caused by the bite plane of the brackets disappears within a few
days after they are placed. Patients that have pain or tension in the temporomandibu-
lar joints feel relief of their symptoms in the first week.
The posterior inocclusion allows a slow eruption of the posterior teeth and helps
to achieve a neuromuscular balance which is important to maintain the results.
The extrusion of the posterior teeth is recommended in patients with short lower
facial height, excessive curve of Spee, and moderate to minimal incisor display. But
the stability of posterior extrusion may be questionable in nongrowing patients.
Incisor intrusion is suggested with long lower facial height, excessive incisor
display at rest and smile, and/or overeruption of upper incisors.
Contrary to what may be supposed, brackets dont come off so easily since the
design of the bite plane protects them (Gorman and Smith 1991).
It is important to normalize the incisors torque in the first phase of treatment.
The use of a 0.017 0.017 Ni-Ti-Cu followed by a 0.0175 0.0175 TMA
wire helps in achieving the desired results.
It is important to remember that the major esthetic factors to be considered when
planning the correction of a deep bite occlusion are incisor display, occlusal plane,
and interlabial gap because the smile line becomes a crucial factor in deciding the
treatment plan.
An individualized retention plan is the KEY for long-term success combining the
control of the new position of the teeth as well as the muscles.
Case Study 1
A 29-year-old patient consulted because she had a significant overbite and lower
anterior crowding. She had used removable appliances when she was 811 years old
with no long-term retention plan.
The midlines were not coincident as she had Class I on the right side and Class
II on the left side.
Her only chief complaint was the lower anterior crowding (Fig. 3.1a, b).
a b
Fig. 3.1 (a, b) Pretreatment buccal front photographs. The important overbite and the lower ante-
rior crowding were evident
Case Study 1 61
Clinical examination revealed some pain at the temporomandibular joints

especially when she was yawning. An important extrusion of the upper incisors was
evident and the lower gingival line was uneven.
The lateral photographs confirmed that the molar relationship was Class I on the
right side and Class II on the left.
The extrusion and retroinclination of the upper central incisor were confirmed.
The gingival line and the occlusal plane were not parallel (Fig. 3.2a, b).
a b
Fig. 3.2 (a, b) Lateral views at the beginning of the treatment
The upper occlusal arch was constricted, more evident on the right side. The
upper lateral incisors were labial inclined, and the discrepancy was about 4 mm in
the upper arch and 9 mm in the lower one (Fig. 3.3a, b).
a b
Fig. 3.3 (a, b) Upper and lower arches where the asymmetry and the lower crowding were quite
evident
62 3 Deep Overbite
Cephalometric analysis showed that she is a severe braquifacial patient. Her

convexity is 1 mm and the lower inferior height only 40. The upper and lower
incisors were retroinclined (+14 and +15, respectively) and the interincisal angle
was 155.
A slight asymmetry between the right and left condyle was present (Fig. 3.4a, b).
a b
Fig. 3.4 (a, b) Pretreatment panoramic and lateral radiographs

2. Normalize overjet and overbite.
3. Maintain periodontal health.
4. Maintain Class I molar on the right side and Class II on the left side.
5. Improve esthetics.
6. Long-term stability.
To achieve the treatment objectives, a treatment plan without extractions was

suggested.
The use of lingual brackets with a bite plane is preferable in order to open the
anterior bite and allow a temporary slight posterior inocclusion.
Indirect bonding was recommended from second molar to second molar in con-
junction with a low load deflection arch (Ni-Ti 0.013) and an open coil spring to
gain space for the lateral incisors (Fig. 3.5a, b).
a b
Fig. 3.5 (a, b) Front and upper occlusal arch at the beginning of the treatment
Case Study 1 63
After 3 months, the upper right and left lateral incisors were indirectly bonded,
and a 0.016 Ni-Ti-Cu wire was recommended. The midline was clearly non-
coincident (Fig. 3.6a, b).
a b
Fig. 3.6 (a, b) Three months in treatment with a 0.016 Ni-Ti-Cu archwire in place
The lower brackets were bonded 3 months later, and some stripping was done in
the lower arch to correct the anterior crowding.
A 0.0175 0.0175 TMA upper archwire was used to normalize anterior torque
(Fig. 3.7a, b).
a b
Fig. 3.7 (a, b) Brackets on the lower arch were indirectly bonding with a Ni-Ti 0.013 archwire
64 3 Deep Overbite
Seven months later, the overbite was normalized as well as the gingival line. To
normalize torque, a TMA 0.017 0.017 archwire was suggested. Oral hygiene
was well maintained (Fig. 3.8a, b).
a b
Fig. 3.8 (a, b) Front photographs with an upper and lower 0.017 0.017 TMA archwire to
control torque
Considering her discomfort in the temporomandibular joints, no Class II elastics

on the left side were recommended.
On the lateral views, Class I molar on the right side and Class II on the left side
were maintained (Fig. 3.9a, b).
a b
Fig. 3.9 (a, b) Lateral views at this moment of the treatment

Case Study 1 65
After 16 months in treatment, the upper and lower arches recovered their normal
shape and transverse dimension. The distocanine and mesio-molar bends were
visible (Fig. 3.10a, b).
a b
Fig. 3.10 (a, b) Upper and lower arcades with the final arches in place
At the end of the treatment, the gingival line was parallel to the occlusal line. The
overbite and overjet were normalized.
Optimal buccal occlusion was possible in concordance with a correct anterior
deocclusion (Fig. 3.11a, b).
a b
Fig. 3.11 (a, b) Final front photographs. As was predetermined, the midlines were not
coincident.
66 3 Deep Overbite
The lateral views confirmed the position of the canines and molars according to
the treatment objectives (Fig. 3.12a, b).
a b
Fig. 3.12 (a, b) Lateral photographs at the end of the treatment
Occlusal views at the end of the treatment. Upper and lower fixed retention was
recommended for a long period along with a temporomandibular splint to control
muscles and relieve discomfort at the TMJ (Fig. 3.13a, b).
a b
Fig. 3.13 (a, b) Upper and lower fixed retention were placed in concordance with the treatment
plan
Case Study 1 67
Panoramic and lateral radiographs at the end of the treatment.

After treatment, the alignment of the roots was normal and no root resorption
was observed on the panoramic radiograph (Fig. 3.14a, b).
a b
Fig. 3.14 (a, b) Panoramic and lateral radiograph at the end of the treatment
The comparison between the pre- and post-treatment lateral cephalograms

showed without doubt that the major changes were dental due to the patients age,
initial in black and final in blue (Fig. 3.15a, b).
a b
Fig. 3.15 (a, b) Superposition of the pre- and post-Ricketts analysis

68 3 Deep Overbite
An important improvement of her smile was visible when pre- and post-treatment
photographs were compared (Fig. 3.16a, b).
The normalization of the deep overbite was clearly observed. All the treatment
objectives were achieved in 22 months of treatment.
a b
Fig. 3.16 (a, b) Comparison of pre- and post-treatment smile
Case Study 2
The following patient was very challenging.

He was sent to the orthodontic department in search for a second opinion to cor-
rect his significant gummy smile without any surgical procedure.
The facial photograph showed an excessive display of the gingiva when smiling
and a huge interincisal diastema.
The overbite was nearly 100 % at the central incisors (Fig. 3.17a, b).
The lower incisors were in contact with the palatal tissues, and the relation
between the incisors length and width was 1:1 (normal 2:1).
He also had a thick periodontal biotype and a large frenum between the central
incisors.
a b
Fig. 3.17 (a, b) Pretreatment frontal and smile photographs

Case Study 2 69
Class I canine and molar were present on the lateral views. The molars were
mesio-inclined and evident distocanine spaces were visible due the reduced size of
the bicuspids. The upper second right bicuspid was in a crossbite position
(Fig. 3.18a, b).
a b
Fig. 3.18 (a, b) Lateral photographs at the beginning of the treatment
The occlusal views confirmed the positive discrepancy, more in the upper arch
than in the lower.
The large frenum was clearly visible and no cavities or restorations were present.
The oral hygiene was normal (Fig. 3.19a, b).
a b
Fig. 3.19 (a, b) The positive discrepancy was confirmed at the occlusal views as well as the mesi-
orotation of the upper molars
70 3 Deep Overbite
The panoramic and lateral radiographs confirmed the significant overbite in a

nongrowing patient. The upper and lower third molars were present in a normal
position, and no extraction procedures were recommended (Fig. 3.20a, b).
a b
Fig. 3.20 (a, b) Pretreatment panoramic and lateral radiographs. The significant overbite and the
diastemata were clearly observed
2. Normalize overbite and overjet.
3. Close the anterior diastema.
4. Maintain Class I molar and canine.
5. Improve periodontal condition.
Taking into account the significant upper arch positive discrepancy, some spaces
distal to the upper canines could be maintained.
Speech therapy during all the treatment was recommended to improve tongue
position.
In order to achieve these objectives, lingual brackets with bite plane were recom-
mended. The first arch was a 0.014 SS (Fig. 3.21a, b).
a b
Fig. 3.21 (a, b) Frontal and occlusal view with the first arch in place
Case Study 2 71
After 6 months, the anterior deep bite was improved due to some extrusion of the
posterior teeth. As the extrusion was very slow, less relapse was expected. Brackets
in the lower arch were bonded at this time.
The interincisal diastema was closed and the papilla was totally recovered
(Fig. 3.22a, b).
a b
Fig. 3.22 (a, b) The interincisal diastema was closed using elastic chains
Class II elastics (1/8 heavy), 2022 h a day, were recommended to improve

occlusion along with a 0.017 0.017 TMA archwire to control anterior torque
(Fig. 3.23a, b).
a b
Fig. 3.23 (a, b) Class II lingual elastics to improve occlusion

72 3 Deep Overbite
After 21 months, the treatment objectives were achieved: the diastema was
closed, the interincisal papillae were totally recovered, overjet and overbite, midline
was coincident, and the gingival line was parallel to the occlusal plane (Fig. 3.24a, b).
Due to a Bolton-positive discrepancy, some space behind the canines was present.
In addition to a removable upper bite plane, a fixed retainer with a coaxial mul-
tistrand stainless steel wire bonded on the palatal and lingual side of the anterior
teeth was placed. No type of frenectomy was decided, before, during, or after
treatment.
a b
Fig. 3.24 (a, b) Front and occlusal final photographs
The pre- and postfacial front photographs confirm the results. The smile was
clearly improved, the diastema was closed, and a normal interdental papilla was
achieved (Fig. 3.25a, b).
Long-term retention plan was advisable.
a b
Fig. 3.25 (a, b) Comparison of pre- and postsmile photographs

Bibliography 73
Conclusions
From the biomechanical point of view, patients with deep overbite benefit from
being treated with the lingual technique more than with labial orthodontics, not
only for esthetic but for functional reasons too.
A deep overbite can be corrected by intrusion of the anterior teeth, extrusion
of the posterior, or a combination of both.
The type of movement depends on the treatment objectives, the incisor expo-
sure when the patient smiles, the thickness of the upper lip, and the patients age.
An individualized mechanotherapy based on biological status is recom-
mended. In some patients, initially bonding brackets in the lower arch may be
suggested. After leveling the lower incisors, maxillary lingual brackets are
bonded to continue treatment.
The anterior-posterior skeletal relationship, the vertical facial biotype, and the
relation between the lip embrasure and the maxillary incisors should be taken
into consideration.
Maintaining an acceptable interlabial gap (34 mm) should be considered
when selecting a strategy for deep bite correction (Lindauer et al. 2005; Harfin
and Urea 2009).
Long-term control is mandatory.
Bibliography
Carano A, Ciocia C, Farronato C. Use of lingual brackets for deep bite corrections. J Clin Orthod.
2008;42:44950.
Forsberg CM, Hellsing E. The effect of lingual arch appliance with anterior bite plane in deep
overbite correction. Eur J Orthod. 1984;6:10715.
Geron S, Vardimon AD. Six anchorage keys in lingual orthodontic sliding mechanics. World J
Orthod. 2003;4:25865.
Geron S, Romano R, Brosh T. Vertical force in labial and lingual orthodontics applied on maxillary
incisors. Angle Orthod. 2004;74:195201.
Gorman JC, Smith RJ. Comparison of treatment effects with labial and lingual fixed appliances.
Harfin J, Urea A. Ortodoncia lingual. Editorial Medica Panamericana. 2009;7:16791.
Lindauer SJ, Lewis SM, Shroff B. Overbite correction and smile esthetics. Semin Orthod.
2005;11:626.
Magnus FC, Hellsing E. The effect of the lingual arch appliance with anterior bite plane in deep
overbite correction. Eur J Orthod. 1984;6:10715.
Efficient Treatment of Open Bite
in Nongrowing Patients 4
The treatment of open bite malocclusions is one of the most challenging.

Normally, patients with this type of malocclusion have a dolichofacial pattern in
combination with speech difficulties and in biting and chewing food. Also, they
have a lack of anterior guidance, posterior crossbite in the molar areas, narrow
maxillary arch, increased lower anterior face, excessive development of the max-
illa, and a short mandibular ramus height that could be aggravated with tongue
interposition at rest and function.
When this situation is present in nongrowing patients, a combination of a skeletal
and dentoalveolar problem is noticeable (Geron and Chaushu 2002; Geron et al.
2004, 2013). Soft tissue evaluation plays an important role in the design of the treat-
ment plan and treatment objectives. Its relation with problems like snoring and
apnea is well established.
Unfortunately, there isnt only one treatment strategy to treat all the nongrowing
open bite patients with a special bracket or wire, but using brackets with long hooks
can help normalize tongue posture (7th Generation Ormco).
Different treatment biomechanics have been suggested, taking into account the
age of the patient, facial biotype, amount of periodontal attachment, number of
teeth, habits, etc. (Kuroda et al. 2007; Park and Kim 2010).
Normally, open bite is always accompanied with tongue thrusting, mouth
breathing, incompetent lips, or finger sucking habit. The correction of these habits
is fundamental to maintain the achieved results; otherwise, relapse is inevitable
(Justus 2001).
After bonding the brackets, the patient is instructed to position the tongue behind
the brackets, during the whole treatment.
Different treatment alternatives will be discussed to correct this malocclusion.
The help of the speech pathologist is imperative. They are also instructed to use
anterior light elastics every night to control the anterior tongue posture.
It is important to remember that the soft palate plays an important role in regulating
the airflow through the nose and mouth.

DOI 10.1007/978-3-319-06832-9_4
76 4 Efficient Treatment of Open Bite in Nongrowing Patients
The retention protocol is essential during a long period of time and has to be
individualized for each patient (Huang 2002; Shapiro 2002). Functional appliances
can help when habits and/or abnormal functions have to be controlled (Teittinen
et al. 2012).
Case Study 1
This 22-year-old patient was worried about the relapse of his open bite, 3 years after
he finished his orthodontic treatment.
At this moment, no respiratory or allergic problems were present.
His tonsils had been removed when he was 7 years old (Fig. 4.1a, b).
a b
Fig. 4.1 (a, b) Pretreatment front and upper occlusal photographs. The relapse is clear
The position and the inclination of the occlusal plane are important when the
treatment objectives are planned.
The labial protrusion of the upper incisors was evident with Class I molar and
almost Class I canine (Fig. 4.2a, b).
a b

Case Study 1 77
It is useful that the panoramic Rx be taken in occlusion for a better definition of

the occlusal plane and the anterior open bite (Fig. 4.3a).
The lateral Rx confirmed the anterior lack of occlusion and the pro-inclination
and intrusion of the upper and lower incisors (inclination of the upper incisor +40
and position +7.65 mm) (Fig. 4.3b).
a b
Fig. 4.3 (a, b) Initial panoramic and lateral radiograph
In order to align and extrude the upper incisors in a secure way, a 0.016 TMA
wire has to be bent in the anterior part between the right and left canine insets. An
activation every 6 weeks is advisable.
Extra torque built into the anterior lingual bracket position can help to tip the incisors
lingually and reinforce extrusion to correct the anterior open bite (Fig. 4.4a, b).
a b
Fig. 4.4 (a, b) 0.016 TMA wire with an occlusal bend between the upper canines
When overjet and overbite are almost normal, clear buttons are bonded to the
upper and lower canines and first bicuspids labial surfaces for vertical rubber bands,
used in order to improve canine guidance (Fig. 4.5a, b).
a b
Fig. 4.5 (a, b) Clear buttons were bonded on the labial side for rubber band elastics
These are the results 20 months after treatment. Midlines are centered and a flat
occlusal plane is normalized. An upper fixed retainer is in place for a long period of
time. Continuous control with the speech pathologist is advisable (Fig. 4.6a, b).
a b
Fig. 4.6 (a, b) At the end of the treatment, a fixed retention wire is advisable for a long time
Case Study 2 79
The comparison of the pre- and postlateral radiographs clearly demonstrated the
improvement of anterior occlusion, the leveling of the occlusal plane, and the nor-
malization of the overjet and overbite (Fig. 4.7a, b).
a b
Fig. 4.7 (a, b) Comparison of pre- and postlateral radiographs
Case Study 2
This 34-year-old patient was sent to the orthodontic department for esthetic and
functional reasons.
Her chief complaint was her midline deviation and the lack of occlusion in the
anterior segment. She received orthodontic treatment when she was 1012 and
1821 years old.
The gingival line is not parallel to the occlusal plane, and upper mild crowding
was present (discrepancy 5 mm). Unesthetic posterior restorations were visible
(Fig. 4.8a, b).
a b
Fig. 4.8 (a, b) Pretreatment front and occlusal photographs

The lateral photographs confirmed an important crossbite in the posterior

segment and the open bite in the anterior region with peg-shaped lateral incisors
(Fig. 4.9a, b).
a b
Fig. 4.9 (a, b) Lateral crossbite with anterior open bite is confirmed
Looking at the panoramic and the lateral Rx, the open bite is confirmed as well
as the absence of the second left lower molar. Lateral crossbite at the bicuspid and
molar area was present (Fig. 4.10a, b).
a b

Case Study 2 81
3. Improve central midlines.
4. Align occlusal plane.
5. Improve gingivo-periodontal tissues.
A nonextraction treatment in the upper arch was decided in spite of the fact she
had a severe dolichofacial pattern with an important anterior open bite.
To achieve Class I canine and normalize the midline, the extraction of the lower
right first bicuspid was suggested.
The first step was to align and level the upper arch. Lingual brackets (7th genera-
tion Ormco Corporation) were bonded from upper second right molar to the second
left molar with a Respond wire (0.0175) for 3 months (Fig. 4.11a, b).
a b
Fig. 4.11 (a, b) Front and lateral photos with the first archwire in place (Respond 0.0175)
To make the right first bicuspid extraction easier, it is recommendable to bond a

bracket on it, 810 weeks before. Meanwhile, the alignment of the lower arch was
performed with a coaxial 0.0175 (Respond). Then a 0.016 TMA arch to complete
Phase I was placed (Fig. 4.12a, b).
a b
Fig. 4.12 (a, b) Upper and lower arches at the end of Phase I
Lateral views 1 week after the right lower first bicuspid extraction were done.
Bands on the first and second molars were placed to enhance anchorage control
(Fig. 4.13a, b).
a b
Fig. 4.13 (a, b) Lateral views 1 week after the first lower bicuspid extraction
Sliding mechanics was recommended. A 0.0175 0.0175 TMA lower arch-

wire was placed to start the distalization of the right canine in order to get a better
alignment and proper space closure for the lower left cuspid with a 4-week activa-
tion (Fig. 4.14a, b).
a b
Fig. 4.14 (a, b) Sliding mechanics to distalize the right lower cuspid
Case Study 2 83
To improve lateral occlusion, esthetic labial buttons were bonded to facilitate the
use of elastics (Fig. 4.15a, b).
a b
Fig. 4.15 (a, b) Esthetic lateral buttons to improve lateral occlusion
To normalize the rotation of the first right upper bicuspid, an elastic chain was
placed between it and the hook of the first molar tube. A 3-week control is advisable
(Fig. 4.16a).
When the lower left canine space was enough, a bracket was bonded.
To correct midlines, another elastic chain was placed between the left lower
central incisor and the right canine (Fig. 4.16b).
a b
Fig. 4.16 (a, b) Elastic chains on the upper and lower arches to correct rotations and incisor
midline
Four months later, the midlines were coincident, and the overjet and overbite had
improved. The continuous use of rubber bands (1/8 heavy) to normalize frontal and
lateral occlusion is important.
Final detailing was accomplished with a 0.0175 0.0175 TMA archwire
(Fig. 4.17a, b).
a b
Fig. 4.17 (a, b) Frontal and right lateral views after the space closure
After 22 months of treatment, the objectives were almost achieved. The occlusal
plane and the gingival line were parallel, and the lateral crossbite was corrected.
Good oral hygiene was accomplished during the whole treatment (Fig. 4.18a, b).
a b
Fig. 4.18 (a, b) Lateral views at the end of the treatment

Case Study 2 85
A fixed retention wire between the upper first bicuspids and between the second
right and first left bicuspid was recommended for a long period of time to maintain
the correction of the inclination and torque of the front teeth (Fig. 4.19a, b).
a b
Fig. 4.19 (a, b) Upper and lower retention wires in place
The comparison between the pre- and post front photographs clearly demon-
strated the improvement of the smile. There is a good normalization of the midlines
and in the transverse dimension as well (Fig. 4.20a, b).
a b
Fig. 4.20 (a, b) Comparison of pre- and post front photographs

Despite her being a nongrowing patient, the upper arch formed and width had
clearly improved. To maintain this result, a correct position of the tongue is helpful.
The help of the speech pathologist is essential.
The use of a night dental plaque to maintain the transversal width is also suggested
(Fig. 4.21a, b).
a b
Fig. 4.21 (a, b) Pre- and post-treatment upper occlusal arch
The pre- and postfrontal smile demonstrated the positive results that were
achieved. Her self-esteem was highly improved (Fig. 4.22a, b).
a b
Fig. 4.22 (a, b) Smile photographs before and after orthodontic treatment
Case Study 3 87
Case Study 3
The following patient was very challenging and one of the most difficult situations
for the patient and for the orthodontists too.
This is the re-treatment of the relapse of a Class II patient that had two missing
bicuspids, extracted in a previous treatment.
This 21-year-old patient came to the office seeking advice about her third orth-
odontic treatment to avoid an orthognathic surgery.
Analyzing the front and lateral photographs, lip incompetence and mild asym-
metry in combination with an increased lower third of the face were visible. In rest
position, buccal respiratory pattern was confirmed (Fig. 4.23a, b).
a b
Fig. 4.23 (a, b) Initial photographs at rest position
Significant musculature tension when the patient closed her mouth was evident.
The nasolabial angle was open and retrusion of the chin was advisable (Fig. 4.24a, b).
a b
Fig. 4.24 (a, b) Musculature tension in closed position is reliable

In the front photographs, the midline deviation is noticeable. A wide overjet was
also evident.
Some enamel decalcification on the labial surface is visible due to her anterior
orthodontic treatments. Her oral hygiene also had to be improved (Fig. 4.25a, b).
a b
Fig. 4.25 (a, b) Front photographs at the beginning of the treatment
The lateral views confirmed that Class II molar and canine were present in spite
of the previous extraction of the first bicuspids.
A crossbite on the left side was also visible (Fig. 4.26a, b).
a b
Fig. 4.26 (a, b) Pretreatment lateral views

Case Study 3 89
The upper occlusal arch confirmed the two extracted bicuspids, rotation of the
first molars, and mild crowding in the anterior teeth.
The lower arch showed mild crowding in the anterior incisors (Fig. 4.27a, b).
a b
Fig. 4.27 (a, b) Upper and lower occlusal view in the first appointment
The panoramic Rx showed the mandibular asymmetry in the height and width of
the mandibular ramus and in the shape of the condyles. Third upper molars were
present (Fig. 4.28a).
The lateral Rx confirmed her dolichofacial pattern (vert 2.24) high-angle case.
The inclination and position of the upper incisors were increased (+11 mm and 39),
and a short mandibular corpus was present (Fig. 4.28b).
a b
Fig. 4.28 Pre treatment panoramic and lateral radiograph

3. Achieve Class I canine.
4. Improve smile esthetics.
Treatment Plan
Since the patient came with both first bicuspids missing, a different approach had to
be performed to achieve Class I canine and normalize overjet and overbite.
After an exhaustive study, the extraction of the upper first molars was decided
taking into account the goal of better esthetic and functional results. The extraction
of the first molars is not a common decision but this was the best choice for this
patient.
To control the vertical and anteroposterior anchorage, a Nance button with a
transpalatal bar in combination with bands on the second and third molars was
placed. To begin the distalization of the second bicuspids, brackets on the labial and
palatal surfaces were bonded (Fig. 4.29a, b).
A simultaneous speech-pathology treatment is highly recommendable since it is
fundamental to achieve and obtain the anterior open bite correction.
a b
Fig. 4.29 (a, b) Front and occlusal view after the extraction of the right and left first molars
Case Study 3 91
Lateral views at this moment of treatment showing the distalization of the second
bicuspids from labial and lingual sites (Fig. 4.30a, b).
a b
Fig. 4.30 (a, b) Lateral views at the beginning of the second phase of treatment
Three months later, brackets were placed on the lower arch, and the beginning of
the distalization of the second bicuspids is well shown (Fig. 4.31a, b).
a b
Fig. 4.31 (a, b) Upper and lower occlusal view

When the second bicuspids reached the desired position, the distalization of
the canines began. The Nance button and the transpalatal arch were maintained
(Fig. 4.32a, b).
a b
Fig. 4.32 (a, b) Front and upper occlusal view showing the distalization of the second upper
bicuspids
Three months later, a sectional rectangular wire was placed to provide torque
control (Fig. 4.33a, b).
a b
Fig. 4.33 (a, b) Sectional arches for better torque control

Case Study 3 93
To improve lateral occlusion, labial intermaxillary rubber band elastics were

recommended (Fig. 4.34a, b).
a b
Fig. 4.34 (a, b) Lateral elastics to improve lateral occlusion
The use of the rubber bands 20 h a day was indicated, and they had to be replaced
every day (1/8 medium) with a 0.016 0.022 SS archwire (Fig. 4.35a, b).
a b
Fig. 4.35 (a, b) Right and left view with the lateral elastics in place
Six months later, the open bite and overjet were normalized with the help of the
speech pathologist. The oral hygiene improved (Fig. 4.36a, b).
a b
Fig. 4.36 (a, b) Overjet and overbite were clearly improved

At this moment, the canines were almost in Class I with normal intercuspidation. The
use of elastics 8 h per day was suggested to maintain lateral occlusion (Fig. 4.37a, b).
a b
Fig. 4.37 (a, b) Night use of elastics was suggested to improve lateral occlusion
To avoid anterior torque loss, the complete closure of the extraction spaces was
performed very slowly with a figure-of-eight wire that was activated every 4 weeks
(Fig. 4.38a, b).
a b
Fig. 4.38 (a, b) Closure of the remnant spaces after first upper molar extractions
Case Study 3 95
Two months later, midlines, overbite, and overjet were almost achieved.
It was advisable for the last archwire (0.0175 0.0175 TMA) to be in place for
at least 3 months (Fig. 4.39a, b).
a b
Fig. 4.39 (a, b) Front and upper occlusal photographs with the last archwire in place
When the lateral views were analyzed, right and left Class I canine was
achieved in spite the first bicuspids and first molars had been extracted. The gin-
gival line was parallel to the occlusal plane. Triangular elastics at night were still
used (Fig. 4.40a, b).
a b
Fig. 4.40 (a, b) Right and left side with the last archwire in place
The comparison of pre- and post-treatment lateral radiographs clearly demon-

strated the open bite correction and the improvement of the position of the mandible
(Fig. 4.41a, b).
a b
Fig. 4.41 (a, b) Pre- and postlateral radiographs
The positive change in the position of the upper and lower lips before and after
treatment was evident. They are more relaxed and now she can close her mouth
easily (Fig. 4.42a, b).
The improvement in the lip closure is remarkable.
a b
Fig. 4.42 Pre and post lip closure

Case Study 3 97
Superimposition of the cephalometric tracings showed that the upper incisors

were retracted with intrusive tipping; meanwhile, the lower incisors were maintained
in their anterior-posterior position (Fig. 4.43a, b).
a b
(CNA)
(x)
cc
cc
(m)
Fig. 4.43 (a, b) Superimposition of pre and post-treatment cephalometric tracings
The correction of the tongue thrust habit is fundamental to avoid relapse, and
overcorrection is always recommendable.
Conclusion
It is well known that open bite etiology is multifactorial. Dental and skeletal
disharmonies are the consequences of these and are more difficult to correct in a
nongrowing patient and are often associated with dolichofacial pattern.
It is important to remember that since the etiology is multifactorial, there is
not a single prescription to treat all the patients.
Muscle equilibrium and control of the tongue posture are important factors to
achieve long-term stability. Every habit that causes an imbalance between the
teeth and muscles can be considered pernicious for post-treatment stability. It is
necessary to know the real causes that produce and increase these habits since
once patients have completed active orthodontic, they tend to slip back into old
habits.
Lingual brackets can help in eliminating the abnormal tongue posture.
Since muscle function is very difficult to control, some authors recommend
not only overcorrecting the initial malocclusion but a long-term retention
plan.
The key is complete habit control to maintain the results.
Bibliography
Geron S, Chaushu S. Lingual extraction treatment of anterior open bite in adults. J Clin Orthod.
2002;36:4416. 2004 Angle Orthod 74:195201.
Geron S, Romano R, Brosh T. Vertical force in labial and lingual orthodontics applied on maxillary
incisors. Theoretical approach. Angle Orthod. 2004;74:195201.
Geron S, Wasserstein A, Geron Z. Stability of anterior open bite correction of adults treated with
lingual appliances. Eur J Orthod. 2013;35(5):599603.
Huang GH. Long term stability of anterior openbite therapy: a review. Semin Orthod.
2002;8:16272.
Justus R. Correction of anterior open bite with spurs: long term stability. World J Orthod.
2001;2:21931.
Kuroda S, Sakai Y, Tamamura N, Deguchi T, Takano-Yamamoto T. Treatment of severe anterior
open bite with skeletal anchorage in adults: comparison with orthognathic surgery outcomes.
Park JH, Kim TW. A new approach to open bite treatment. Oral Health J. 2010;100(9):258.
Shapiro PA. Stability of open bite treatment. Am J Orthod Dentofacial Orthop. 2002;121:5668.
Teittinen M, Tuovinen V, et al. Long term stability of anterior open bite closure corrected by surgi-
cal orthodontic treatment. Eur J Orthod. 2012;34:23843.
Use of Pendulum with Lingual
Appliances 5
The normalization of the anteroposterior position of the upper first molars is one of
the most important challenges for orthodontists.
Different choices had been presented in the literature. Among them, the use of a
pendulum as a noncompliance appliance especially in adolescents and adults is
recommendable (Harfin and Urea 2010).
The design allows orthodontists not only to normalize the position but also to
correct the rotation and the transversal dimension in the posterior region.
It was described by Hilgers in 1992, and some years later, a new model with a
palatal expansion screw to correct the transversal width was suggested (Hilgers
1983, 1992).
It is one of the non-extraction treatment modalities that dont require patient
cooperation with acceptable esthetics and comfort.
A large acrylic button is used as an anchor component in combination with a
0.036 TMA springs that produce a light continuous force against the molars. Four
stainless steel arms are bonded with composite on the occlusal surfaces of the first
and second bicuspids (Fig. 5.1a, b).
a b
Fig. 5.1 (a, b) Different pendulum models with two and four springs

DOI 10.1007/978-3-319-06832-9_5
100 5 Use of Pendulum with Lingual Appliances
By opening the horizontal loop, buccal or distal uprighting forces are created
producing a bodily movement of the molars (Byloff and Darendeliler 1997a; Joseph
and Butchard 2000).
When the second molar is present, a double spring is suggested.
The amount and frequency of the activation is related to the treatment
objectives.
Dr. Hilgers suggests beginning with an activation of 90 of the TMA springs, but
experience has demonstrated that a 45 activation of the molar spring is highly rec-
ommendable to achieve the distalization of the whole molar thus avoiding the distal
inclination of the crown. Only two or three activations are mostly necessary to
achieve the desired results.
The springs can produce about 56 mm of distal movement in 45 months
(Byloff and Darendeliler 1997b).
When the molars are in the desired position, the SS wire retention arm on the
second bicuspid should be cut.
In general, they drift distally in 2 or 3 months, and in some cases, a bracket with
a partial arch is used. The same procedure is used for the first premolar.
Another important issue is how to maintain the position of the molars. A modi-
fied Nance button appliance with a transpalatal bar is suggested.
It is crucial that it be cemented the same day the pendulum is removed (Fig. 5.2)
(Bennet and Hilgers 1999; Geron et al. 2004).
Fig. 5.2 A modified Nance

button appliance with a
transpalatal bar to maintain
the molar position
A complete distalization of the bicuspids has to be completed before the pendulum

is removed.
For the retrusion of the anterior teeth, a 0.016 0.022 SS archwire is used with
a figure-of-eight ligature from canine to canine and an elastic chain from the hook
of the canine to a loop of the appliance or to the second molar.
In very few cases, some protrusion of the incisors is observed as a side
effect (Bussik and McNamara 2000). More control during the activation period is
necessary to avoid this problem. Until now, no undesirable third molar impaction
was observed.
Case Study 1 101
Case Study 1
The following 28-year-old patient is a clear example. His chief complaint was the
position of the upper lateral incisors, especially the right one.
He used some type of removable appliance when he was 811 years old.
Besides the position of the upper lateral incisors, an important overbite was present
in combination with the retroinclination of the central incisors. The gingival line
and the occlusal plane were not parallel, and an important gummy smile was present
on the central incisor level (Fig. 5.3a, b).
a b
Fig. 5.3 (a, b) Pretreatment front and smile photographs
A complete Class II molar and canine were observed on the lateral views. The
retroinclination of the central incisors was evident. The oral hygiene was normal.
No TMD symptoms were present (Fig. 5.4a, b).
a b
The labial position of the lateral incisors was confirmed when the upper arch was
analyzed as well as the palatal inclination of the central incisors.
The discrepancy was 4 mm in the upper arch and 5 mm in the lower arch
(Fig. 5.5a, b).
a b
Fig. 5.5 (a, b) Upper and lower arcades before orthodontic treatment
Since the panoramic Rx was taken in occlusion, the extrusion of the lower incisors
was clearly visible. The left lower third molar was mesioinclined (Fig. 5.6a).
The lateral Rx confirmed the significant overbite. The interincisal angle (156),
the convexity (+6.5 mm), and the posterior facial height (73.5) were increased
(Fig. 5.6b).
The position of the upper incisor was +0.77 mm with 12 of inclination and the
lower incisor was 4 mm and 13.
a b
Fig. 5.6 (a, b) Panoramic Rx in occlusion and lateral radiograph at the beginning of the
treatment
Case Study 1 103
2. Achieve Class I canine and molar.
4. Improve esthetics.
5. Maintain or improve periodontal health.
6. Achieve long-term stability.
After analyzing different alternatives and taking into consideration that the
patient didnt want orthognathic surgery nor extraction of the first bicuspids, a pen-
dulum appliance was placed to normalize the position of the first and second upper
molars.
This is the situation 2 and 4 months after the pendulum was bonded. A central
screw was added to control the upper arch width. Only two activations were needed
to distalize the molars (Fig. 5.7a, b).
a b
Fig. 5.7 (a, b) Results after 2 and 4 months in treatment
After the second bicuspids were distalized, the pendulum was removed, and the
brackets on the first bicuspid were bonded to initiate their distalization. Other brack-
ets on the labial side of the second bicuspids were added in conjunction with a
0.016 0.022 partial archwire to control anchorage (Fig. 5.8a, b).
a b
Fig. 5.8 (a, b) Different stages of the bicuspid distalization

When the first bicuspids were totally distalized, all the anterior brackets were
bonded and a low load deflection arch was placed (0.014 SS).
The position of the lateral and central incisors was almost corrected, and a
figure-of-eight ligature was placed to improve their position (Fig. 5.9a, b).
a b
Fig. 5.9 (a, b) Front and occlusal view with all the anterior brackets in place and a 0.014 SS
archwire
The lateral views confirmed that the molars were in Class I as well as the bicuspids.
Buttons on the labial surface of the molars were bonded for the use of Class II
elastics (Fig. 5.10a, b).
a b
Fig. 5.10 (a, b) Right and left Class I molar was achieved after the use of the pendulum for 6
months
Case Study 1 105
The use of Class II elastics from the hook of the lingual bracket of the canines to
a clear button that was adhered to the labial surface of the first lower molars,
contributed in achieving Class I in the molar and bicuspid areas (Fig. 5.11a, b).
The Class II elastics had to be used 2223 h a day (1/8 heavy).
a b
Fig. 5.11 (a, b) Class II elastics were recommended to improve Class I molar occlusion
At the end of the treatment, the initial objectives were achieved. The maxillary
and mandibular arches were aligned, the overjet and overbite were totally normalized,
midlines were coincident, and the gingival line was parallel to the occlusal plane
(Fig. 5.12a).
The lateral Rx confirmed the intrusion of the upper central incisors and the Class
I molar (Fig. 5.12b).
a b
Fig. 5.12 (a, b) Front photograph and lateral radiograph at the end of the treatment
The normalization of the incisor position and the occlusal plane was clearly vis-
ible. Class I canine and molar were attained (Fig. 5.13a, b).
a b
Fig. 5.13 (a, b) Post-treatment right and left side
A 0.0175 multistranded stainless steel lingual fixed retainer from the first right
bicuspid to the left first bicuspid in the upper and lower arches was bonded the same
day the lingual brackets were removed (Fig. 5.14a, b). The active treatment time
was 22 months.
a b
Fig. 5.14 (a, b) Upper and lower lingual fixed retainer from the right to the left first bicuspid
Case Study 1 107
Good root alignment with no signs of root resorption was shown after treatment.
The interincisal angle was totally normalized (131) and the profile was improved
(Fig. 5.15a, b).
a b
Fig. 5.15 (a, b) Final radiographs
The comparison of the front dental photographs pre- and post-treatment showed
all the favorable improvement that was obtained. Smile esthetics was greatly
improved and the patient was fully satisfied with the results. No signs of problems
in the temporomandibular joint were present (Fig. 5.16a, b).
a b
Fig. 5.16 (a, b) Comparison pre- and postsmile photographs

The comparison of the pre- and post-treatment Rickettss analysis clearly dem-
onstrated the dental movements that were achieved (Fig. 5.17a, b), initial in black
and post-treatment in red.
a I b I
F F
N
ENA
CC
M CC
Fig. 5.17 (a, b) Comparison of the pre- and post-Rickettss analysis
Three years after the completion of the treatment, the position of the teeth was
maintained. The treatment objectives were fully achieved (Fig. 5.18a, b).
a b
Fig. 5.18 (a, b) Control 3 years post-treatment. The incisal guidance was maintained
Case Study 2 109
Case Study 2
This is a 32-year-old male with no history of important disease or temporomandibu-

lar problems. He was referred from another orthodontist for lingual orthodontic
treatment, and his chief complaint was the position of the upper lateral incisors.
This was going to be his third orthodontic treatment.
The front photograph revealed an important extrusion at the central incisors
region and the labial position of the lateral incisors (Fig. 5.19a, b).
a b
Fig. 5.19 (a, b) Front photographs at the beginning of the treatment. The extrusion of the upper
incisors was confirmed
Class II molar and canine were evident and good oral hygiene was present. A
porcelain crown had been placed on the right lateral lower incisor 3 years earlier
(Fig. 5.20a, b).
a b
The occlusal photographs confirmed the retroposition of the upper central inci-
sors and the labial position of the lateral ones.
Three millimeter of negative discrepancy was present in the lower arch
(Fig. 5.21a, b).
a b
Fig. 5.21 (a, b) Upper and lower arches before treatment. A porcelain crown on the right lower
lateral incisor had been placed before
The Rx confirmed the deep overbite in the anterior region. It is important to pay
attention to the interincisal angle (150), the inclination of the upper incisors (+15),
and the deep overbite (+7 mm) in a nongrowing patient (Fig. 5.22a, b).
a b
3. Achieve Class I canine and molar.
5. Improve smile esthetic.
The following treatment plan was determined to achieve these objectives. For the
normalization of the lateral occlusion, the use of a pendulum was considered the
best option as it acts as a noncompliance appliance.
Case Study 2 111
The following photos demonstrate the difference between the first day of activa-
tion and 3 months later. Normally, some overcorrection was suggested before the
bonded support on the second bicuspid was removed (Fig. 5.23a, b).
a b
Fig. 5.23 (a, b) A clear demonstration of the amount of space that can be achieved in 3 months
In some patients, the loop of the pendulum was used as anchorage to retract the
anterior teeth. In this patient, brackets on the second bicuspid were bonded to
accomplish their retraction in conjunction with an elastic chain until the second
molars. A figure-of-eightt ligature was used for splinting the first and second molars
(Fig. 5.24a, b).
a b
Fig. 5.24 (a, b) A practical method for the distalization of the second upper bicuspids
To improve dental interdigitation, plastic or metal buttons with intermaxillary

elastics were used (Fig. 5.25a, b).
a b
Fig. 5.25 (a, b) Clear buttons along with intermaxillary elastics to improve occlusion
After the distalization was completed, a transpalatal arch was placed to maintain
the arch width in conjunction with a labial and palatal sectional posterior arch to
reinforce anchorage (Fig. 5.26a, b).
a b
Fig. 5.26 (a, b) Frontal photograph with the transpalatal arch in place
Case Study 2 113
To begin alignment, upper anterior lingual brackets were bonded with a coaxial
0.0175 arch. In the mandible, lingual arch brackets were placed from the right
second bicuspid to the left second bicuspid, except for the right canine due to lack
of space with a 0.013 Ni-Ti arch (Fig. 5.27a, b).
a b
Fig. 5.27 (a, b) Alignment and leveling of the upper and lower arches
These were the results after 24 months of treatment. Overjet and overbite were
normalized, and now, the gingival line was parallel to the occlusal plane. Good oral
hygiene was maintained during the whole treatment (Fig. 5.28a, b).
a b
Fig. 5.28 (a, b) Final front photographs

Class I canine and molar were achieved with a good intercuspidation in the molar
and premolar areas (Fig. 5.29a, b).
a b
Fig. 5.29 (a, b) Post-treatment lateral views
For retention, a 0.0195 multistrand stainless steel lingual fixed retainer was
bonded from canine to canine in the maxilla. In the mandible, a similar fixed retainer
wire was placed between the right first bicuspid to the left first bicuspid. As always,
long-term retention was suggested (Fig. 5.30a, b).
a b
Fig. 5.30 (a, b) Retention wires were bonded the same day the brackets were removed
Case Study 2 115
An important improvement of his smile was confirmed when pre- and post-
treatment front photographs were compared. The total time of treatment was 24
months (Fig. 5.31a, b).
a b
Fig. 5.31 (a, b) Comparison of pre- and post-treatment smile. The improvement is clearly
noticeable
Since the patient was a nongrowing patient, the major changes will be only in the
dental field. The normalization of the position of the molar was significant as well
as the position and inclination of the upper and lower incisors (Fig. 5.32a, b).
a b CNA
(X)
CC
(M)
CC
Fig. 5.32 (a, b) Pre- and post-Ricketts superpositions

Front photographs 3 years after treatment when the patient returned for a reten-
tion control. The occlusion was almost stable (Fig. 5.33a, b).
a b
Fig. 5.33 (a, b) A control 3 years post-treatment
Lateral views at the control appointment. Class I molar and canine were well
conserved (Fig. 5.34a, b).
a b
Fig. 5.34 (a, b) Class I molar and canine were stable after 3 years post-treatment
The retention wires were well maintained during this whole period (Fig. 5.35a, b).
a b
Fig. 5.35 Upper and lower occlusal arches 3 years post treatment
Bibliography 117
Conclusion
This is an ideal appliance to normalize the anteroposterior position of the molars

and at the same time to correct lateral crossbites at any age, but its use is more
recommendable in adolescents and young adults.
The need for minimal patient cooperation of the pendulum is one of the most
desirable qualities when compared with other appliances (Scuzzo 1999; Wong
et al. 1999; Kinzinger 2004).
This appliance is totally invisible and it does not interfere with eating or
phonation.
The combination of the pendulum with lingual brackets demonstrates an effi-
cient method to achieve the desired objectives with a totally esthetic appliance.
Bibliography
Bennet RK, Hilgers JJ. The pendulum appliance: maintaining the gain. Clin Impressions.
1999;3:69.
Bussik TJ, McNamara JA. Dentoalveolar and skeletal changes associated with the pendulum
appliance. Am J Orthod Dentofacial Orthop. 2000;117:33343.
Byloff FK, Darendeliler MA. Distal molar movement using the pendulum appliance. Part 1: clinical
and radiological evaluation. Angle Orthod. 1997a;67:24960.
Byloff FK, Darendeliler MA. Distal molar movement using the pendulum appliance Part II: The
effects of maxillary molar root uprighting bends. Angle Orthod. 1997b;67:26170.
Geron S, Kinzinger G, Fritz U. Efficiency of a pendulum appliance for molar distalization related
to second and third molar eruption stage. Am J Orthod Dentofacial Orthop. 2004;125:823.
Harfin J, Urea A. Ortodoncia Lingual: procedimientos y aplicacin clinica. Buenos Aires,
Argentina: Editorial Mdica Panamericana; 2010.
Hilgers J. The pendulum appliance. An update. J Clin Orthod. 1983;17:396413.
Hilgers J. The pendulum appliance for Class II non compliance therapy. J Clin Orthod.
1992;26:12732.
Joseph AA, Butchard CJ. An evaluation of the pendulum distalizing appliance. Semin Orthod.
2000;6:12935.
Kircelli KB, Pectas Z, Kircelli C. Maxillary molar distalization with a bone-anchored pendulum
appliance. Angle Orthod. 2006;76:6509.
Kinzinger G, Fritz UB, Sander FG, Diedrich PR. Efficiency of a pendulum appliance for molar
distalization related to second and third molar eruption stage AJODO 2004;125:823.
Scuzzo G, Takemoto K, Pisani F. Maxillary molar distalization with a modified pendulum appliance.
J Clin Orthod. 1999;33:64550.
Wong AM, Rabie AB, Haag U. The use of the pendulum appliance in the treatment of Class II
malocclusion. Br Dent J. 1999;187:36770.
Impacted Canines
6
The treatment of impacted canines is a true challenge not only for the orthodontist
or the surgeon but for the patients too. Its prevalence is about 1 % in the general
population (Warford et al. 2003).
It was described that 85 % of them are palatal impactions and only 15 % are
labial impactions (Thilander and Jakobson 1968).
Since the maxillary canines have the longest distance between the place of their
formation and the place of eruption, they are more liable to problems in their path
of eruption.
They play a vital role in facial appearance, dental esthetics, arch development,
and functional occlusion.
The most common reasons that cause impaction are usually localized: lack of
space, supernumerary teeth, tumors, dentigerous cysts, trauma, dilacerations of the
root, idiopathic conditions, or aberration in the normal pattern of eruption (Bishara
1992, 1998).
Some studies have suggested that peg-shaped or missing lateral incisors could be
an etiological factor (Becker et al. 1984; Becker and Chaushu 2003; Brin et al.
1986).
Its early detection may reduce complications and treatment time.
Ideally, the orthodontic treatment of a palatally impacted canine is to bring the
tooth to its normal position without causing any periodontal, tissue, or tooth
damage.
Where prognosis is a concern, normally it is good. There is a positive correlation
between the original position of the canine, root shape and length, type and height
of periodontal attachment, and dilacerations of the root. The surgical protocol and
type of biomechanics during and after the surgical procedure is important, no matter
which type of brackets is used.
Resorption of the central or lateral incisor roots can be expected to be present in
3040 % of the cases, and they are visualized about 50 % more often by CT scan-
ning than by intraoral X-rays (Ericson and Kurol 1986, 1987a, 2000; Mah and
Alexandroni 2010).

DOI 10.1007/978-3-319-06832-9_6
120 6 Impacted Canines
Working together with the surgeon is of paramount importance (Cassiano et al.

2012).
Although digital panoramics or periapical Rxs provide satisfactory diagnostic
images, they lack the accuracy necessary for assessing buccal or palatal root resorp-
tion of the adjacent teeth (Ericson and Kurol 2000).
New diagnostic tools as cone beam and three-dimensional radiographs
are fundamental to determine the real position of the impacted canine
(Fig. 6.1a, b).
a b
Fig. 6.1 (a, b) Three-dimensional radiographs are relevant to determine the exact position of the
impacted canines.
The best surgical treatment has to be determined by the surgeon, according to its
tridimensional position, amount of bone, etc.
It is highly recommended that the surgical exposure and placement of a
bracket or an auxiliary attachment be performed in the same procedure (Chaushu
et al. 2004).
There are some cases where extraction would be the best choice specially
when there is no space between the lateral incisor and the bicuspid and the
canine is displaced too high. Extraction is also indicated when the tooth is
ankylosed or with an evident dilacerated root. Another situation could be when
the canine is lodged between the roots of the central incisors or between the
roots of the central and lateral incisors and orthodontic movement would jeop-
ardize these teeth (Becker 1981, 2010).
Creating adequate space in the dental arch to accommodate the impacted canine
before the surgical procedure is suggested.
6 Impacted Canines 121
A new lingual ballista spring was developed by the authors to improve the
eruption of impacted canines (Fig. 6.2a).
It is easy to make and manipulate. TMA 0.0175 0.0175 wire or 0.018 SS is
recommendable to make the ballista spring.
The design includes a distal and a mesial loop for better force and torque control.
The distal one is located in front of the molar tube and the mesial one on the palatal
side of the first bicuspid. The activation is done by a wire ligature (Fig. 6.2b) every
34 weeks.
It is very simple to construct, insert, and ligate as it is independent from other
parts of the appliance.
a b
Fig. 6.2 (a, b) New lingual ballista spring and its activation
The force of the spring is proportional to the diameter and length of the wire and
allows the extrusion of the canine without compressing the canine toward the adja-
cent teeth. The force is well controlled and easily modified according to the original
position of the impacted tooth (Fig. 6.3a, b).
It is strongly recommended that the tooth be erupted vertically and downward
through the palatal tissue and then moved buccally into its place in the arch.
a b
Fig. 6.3 (a, b) Activation and ligation of the ballista spring

Another option is to use the ballista spring to erupt the canine before the anterior
brackets are placed.
This protocol helps protect the roots of the adjacent teeth.
The canine should be moved using light and continuous force, not exceeding
80100 gs.
A controlled anchorage is necessary to avoid unwanted effects on the molars or
anchorage unit.
This 28-year-old patient came to the office looking for an esthetic solution.
She had lost the temporary canine 1 week earlier and was worried about it
(Fig. 6.4a, b).
The occlusal Rx showed the position of the canine and the length of the root. The
objective of the treatment was to proper position the impacted upper right canine
into the arch.
a b
Fig. 6.4 (a, b) Occlusal photograph and radiograph of a 28-year-old patient with an impacted
right canine
One week after the surgery, the traction phase began.

It is highly advisable to move the impacted canine occlusally first, and when the
whole crown is totally erupted, a buccal movement can begin.
If the canine is in close proximity to the incisor roots and a buccally directed and
heavy force is applied, it will contact the roots and may cause important and irre-
versible damage to them.
Composite temporary crown was placed in order to improve esthetics. It is rec-

ommendable for temporary composite pontics to be bonded on the labial and mesial
surface of the first bicuspid (Fig. 6.5a).
After the crown of the canine was totally erupted, an open coil spring was used
to gain space for the upper lateral incisors in combination with a 0.016 TMA arch
(Fig. 6.5b).
a b
Fig. 6.5 (a, b) Occlusal view with the temporary crown in place and with the open coil spring to
gain space for the lateral incisors
Three months later, the upper lateral incisors were bonded (Fig. 6.6a, b) to
complete the upper arch.
a b
Fig. 6.6 (a, b) Brackets on the upper lateral incisors were bonded with individual caps
Bearing in mind that obtaining normal gingivo-periodontal tissues is also an

objective, slow and controlled movements are advisable as it was observed on the
lateral and occlusal view (Fig. 6.7a, b).
a b
Fig. 6.7 (a, b) Lateral and occlusal view 6 months later
When the canine was completely aligned within the dental arch, a finishing
archwire TMA 0.0175 0.0175 was placed for a better control of torque
(Fig. 6.8a, b).
Individualized distal canine and mesio-molar bends were incorporated during
the whole treatment.
a b
Fig. 6.8 (a, b) A finishing archwire 0.0175 0.0175 in place with distal canine and mesio-molar
bends
At the end of the treatment, the palatally impacted maxillary right canine was
positioned into its proper alignment. The gingivo-periodontal tissues around the
canine were totally normal.
The gingival line was parallel to the occlusal plane and the papillae were totally
recovered.
Total treatment time was 24 months.
For retention, a fixed retention wire was placed in conjunction with a removable
plate for night use (Fig. 6.9a, b).
a b
Fig. 6.9 (a, b) Lateral and occlusal view at the end of the treatment
The smile and the panoramic radiograph at the end of the treatment confirmed
the previous results (Fig. 6.10a, b).
a b
Fig. 6.10 (a, b) Smile and panoramic radiograph at the end of the treatment
A control 3 years posttreatment showed no attachment loss at the site of the

impacted canine, and no root resorption of the adjacent teeth was seen.
The results were stable and no signs of relapse were visible (Fig. 6.11a, b).
a b
Fig. 6.11 (a, b) Front and lateral photographs 3 years posttreatment. The gingivo-periodontal tis-
sues were completely normal
A 32-year-old patient came to the office for a second opinion regarding her right
and left impacted canines.
The first orthodontist she had seen determined that the best option was the
extraction of the canines and to replace them with implants. After consulting
with another dentist, a new consultation with a different orthodontist was
suggested.
After analyzing all her Rx studies, lingual orthodontic treatment was recom-
mended to normalize the position of the impacted canines. The left canine was more
mesioinclined than the right one (Fig. 6.12a, b).
a b
Fig. 6.12 (a, b) Pretreatment panoramic and occlusal radiograph

The midlines were not coincident, and in the palatal view, the absence of the
permanent canines was confirmed while the temporary ones were still in place
(Fig. 6.13a, b).
a b
Fig. 6.13 (a, b) Front and occlusal photographs before treatment
It is crucial to remember that the surgeon has to open a flap that allowed bonding
a bracket or at least a button to the palatal or labial surfaces of the canines during the
same procedure.
One week later, a lingual ballista spring was placed and activated every 2 weeks
in order to extrude the crown portion of the teeth and in this way take them far back
from the upper incisors avoiding any possible root resorption (Fig. 6.14a, b).
a b
Fig. 6.14 (a, b) One week and 3 months occlusal view after surgery
It is advisable not to put brackets on the central and lateral incisors until all the
crowns of the canines are extruded. Three months later, brackets on the central
incisors were bonded, and since more space was needed, a Ni-Ti open coil spring
was placed to gain space in the arch for the cuspids to come (Fig. 6.15a, b).
a b
Fig. 6.15 (a, b) Three months later, brackets on the central incisors with a Ni-Ti coil spring were
placed
To start moving the cuspids to the labial side, a partial sectional wire with a Ni-Ti
open coil spring between the canines was placed in combination with a 0.16
Cu-Ni-Ti. The palatal side of the temporary canines was reduced in each visit to
maintain esthetics (Fig. 6.16a, b).
Three months later, the bracket on the right upper lateral was placed while on the
left side, more space was needed.
a b
Fig. 6.16 (a, b) A sectional wire with a coil spring was placed to move labially the canines
It is common that one cuspid moves faster than the other.

When the canines were almost in place, a 0.016 TMA with the disto-canine and
mesio-molar bends was placed, and the extraction of the left temporary canine was
necessary before the lateral incisor was included in the arch (Fig. 6.17a, b).
a b
Fig. 6.17 (a, b) A TMA 0.016 archwire was placed to complete the alignment
To finish the treatment, a 0.0175 0.0175 TMA archwire was used to normal-
ize torque (Fig. 6.18a).
A fixed long-term retention was also advisable to maintain the new position of
the canines (Fig. 6.18b).
a b
Fig. 6.18 (a, b) To normalize torque, a 0.0175 0.0175 TMA was recommended for 3 months
before the retention wire was placed for a long term
The comparison between the beginning and at the end of the orthodontic
treatment clearly demonstrated the excellent results that were achieved with a very
simple and controlled mechanics (Fig. 6.19a, b).
a b
Fig. 6.19 (a, b) Comparison between initial and final occlusal photos
Conclusions
The presence of maxillary permanent canines is important for an attractive smile,
and they are also essential for a good functional occlusion.
It is also well known that management of impacted canines is often extremely
challenging not only for the orthodontist but also for the patient.
It is highly recommended that periodontists perform the surgery as they nor-
mally handle the gingivo-periodontal tissues with more caution.
The patient has to be aware of the advantages of the treatment as well as risks
such as possible root resorption of the canine and adjacent teeth, ankylosis, or
loss of tooth vitality.
Dr. Rafi Romano (Romano 2011) assessed that treating palatally impacted
canines with lingual orthodontics is more difficult, based on the short interbracket
distance and the space between the lingual brackets and the adjacent teeth.
The experience demonstrated that the lateral incisors should be bonded when
the impacted canine is almost in place.
It is clearly demonstrated that the lingual ballista spring is a simplified
orthodontic system for treating palatally impacted canines (Jacoby 1979).
An interdisciplinary team (periodontist, surgeon, orthodontist) is necessary to
erupt the impacted canine to guide it to its normal position (Kokich 2004).
A careful selection of the best and most reliable surgical and orthodontic tech-
nique is essential for successful results (Woloshyn et al. 1994).
Excellent outcome with a long-term follow-up confirms the results.
Bibliography 131
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maxillary cuspids. Angle Orthod. 1984;54:21825.
Becker A, Chaushu S. Success rate and duration of orthodontic treatment for adult patients with
palatally impacted maxillary canines. Am J Orthod Dentofacial Orthop. 2003;124:50914.
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palatally displaced cuspids. Angle Orthod. 1981;51:249.
Becker A, Chaushu G, Chaushu S. Analysis of failure in the treatment of impacted maxillary
canines. Am J Orthod Dentofacial Orthop. 2010;137:74354.
Bishara SE. Impacted maxillary canines: a review. Am J Orthod Dentofacial Orthop.
1992;101:15971.
Bishara SE. Clinical management of impacted maxillary canines. Semin Orthod. 1998;4:8798.
Brin I, Becker A, Shalhav M. Position of the maxillary permanent canine in relation with anomalous
or missing lateral incisors. A population study. Eur J Orthod. 1986;8:126.
Pereira CCS, Jardim ECG, et al. Surgical-orthodontic traction for impacted maxillary canines: a
critical review and suggested protocol. Stomatos. 2012;18:7883.
Chaushu S, Chaushu G, Becker A. The role of digital volume tomography in the imaging of
impacted teeth. World J Orthod. 2004;5:12032.
Ericson S, Kurol J. Radiographic assessment of maxillary canine eruption in children with clinical
signs of eruption disturbances. Eur J Orthod. 1986;8:13340.
Ericson S, Kurol J. Radiographic examination of ectopically erupting maxillary canines. Am J Orthod
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Ericson S, Kurol J. Incisor resorption caused by maxillary cuspids: a radiographic study. Angle
Orthod. 1987b;57:33246.
Ericson S, Kurol J. Resorption of incisors after ectopic eruption of maxillary canines. A CT study.
Angle Orthod. 2000;70:41523.
Jacoby H. The ballista spring system for impacted teeth. Am J Orthod. 1979;75:14351.
Kokich VG. Surgical and orthodontic management of impacted maxillary canines. Am J Orthod
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Mah J, Alexandroni S. Cone Beam computed tomography in the management of impacted canines.
Semin Orthod. 2010;16:199204.
Romano R. Lingual and esthetics orthodontics. London: Quitessence; 2011.
Thilander B, Jakobson SO. Local factors in impaction of maxillary canines. Acta Odontol Scand.
1968;26:1458.
Warford JH, Grandhi RK, Tira DE. Prediction of maxillary canine impaction using sectors and
angular measurements. Am J Orthod Dentofacial Orthop. 2003;124:6515.
Woloshyn H, Artun J, Kennedy DB, Joondeph DR. Pulpal and periodontal reactions to orthodontic
alignment of palatal impacted canines. Angle Orthod. 1994;64:25764.
Clinical Cases
7
The importance of the facts that people place on an esthetically pleasing smile has
grown considerably over the last years.
Esthetics is not only important for people as a result of the treatment but during
the treatment itself.
Lingual orthodontics is the perfect answer for these patients, since they can
achieve the desired results without visible brackets.
This chapter will focus on three of the most frequent types of clinical cases that
adults have. The following examples demonstrate three of the most common problems
the patients would like treated. The first case was treated with the extraction of the
upper first bicuspids in spite of a significant compression of the upper arch. In the
second one, the spaces of a previously extracted upper and lower first molars were
closed, and in the third clinical case, correction of Class II molar with a pronounced
deep overbite was corrected using a combination of pendulum and lingual brackets.
It will provide a step by step description on how to treat them, achieving
outstanding results with a very controlled protocol.
These results can be achieved regardless of the type of lingual brackets used.
Diagnosis, anchorage, treatment, and retention plan are the most important factors
to consider (Harfin and Urea 2010).
Closing extraction spaces with lingual orthodontics requires making a critical
protocol to avoid undesirable tooth inclination or torque.
It is essential to align and level the arches and overcorrect the anterior torque
before the retraction process begins.
Since every patient is different, individualized treatment and biomechanics is
required.

DOI 10.1007/978-3-319-06832-9_7
134 7 Clinical Cases
Case Study 1
This is a 36-year-old patient who complained about upper and lower crowding in
combination with upper incisor protrusion. She had no history of general disease or
trauma.
Compression of the upper arch, more on the right side, was evident.
Upper and lower midlines werent coincident (Fig. 7.1a, b).
a b
Fig. 7.1 (a, b) Front photographs of a 36-year-old patient with an evident compression on the
right side
Class I right and left molar was present. The first upper bicuspids had an observ-
able gingival retraction and the lower left canine was mesioinclined.
Oral hygiene was fairly good (Fig. 7.2a, b).
a b

Case Study 1 135
There was 5 mm of discrepancy in the upper arch and 6 mm in the lower. Some
restorations had to be changed and improved. The lateral compression of the lateral
sides was clearly visible (Fig. 7.3a, b).
a b
Fig. 7.3 (a, b) Upper and lower arches at the beginning of the treatment
The panoramic radiograph confirmed that the third molars had been extracted
during the previous orthodontic treatment and no important bone loss was present.
Cephalometric evaluation revealed the visible proclination of the upper incisors
(+11) and the protrusion of the upper lip (Fig. 7.4a, b).
a b
Fig. 7.4 (a, b) Panoramic and lateral radiographs before treatment

Treatments Objectives
1. Align and level de arches.
2. Achieve normal overjet and overbite.
3. Improve smile esthetics.
Treatment Plan
To achieve the treatment objectives in this nongrowing patient, the extraction of the
right and left first bicuspids was recommended.
For personal reasons, esthetic brackets were used on the lower arch with a non-
extraction protocol.
A long-term fixed retention plan was suggested.
To initiate the alignment phase, lingual brackets (STB lingual brackets, Ormco
Corporation) were bonded indirectly from second molar to second molar except the
first upper bicuspids, right cuspid, and left central incisor. A slight open coil spring
was added to gain space for the upper central incisor (Fig. 7.5a, b).
a b
Fig. 7.5 (a, b) Front and occlusal photographs at the beginning of the treatment
Case Study 1 137
After 3 months and when the upper incisors were almost aligned, the extraction
of the first bicuspids was performed and a 0.016 TMA archwire was placed to
complete Phase I.
For esthetic reasons, a composite pontic was bonded on the mesial and labial
surface of the second bicuspids (Fig. 7.6a, b).
a b
Fig. 7.6 (a, b) After 3 months of treatment with the extraction of the first bicuspids and the
esthetic pontics in place
Sliding mechanics was recommended to close the extraction spaces and retrude
the upper anterior teeth. A figure-of-eight ligature between the upper canines was
recommended to achieve en masse retraction.
To avoid transverse bowing side effect, sagittal and transversal reverse curves
were added to the 0.0175 0.0175 TMA archwire (Fig. 7.7a, b).
a b
Fig. 7.7 (a, b) Front and occlusal view using sliding mechanics to close the extraction spaces
When nearly 50 % of the extraction spaces were closed, lower esthetic

pre-programmed brackets with metal slot were bonded from the first right molar to
the left first molar with a stainless steel 0.014 archwire to begin the alignment and
leveling phase (Fig. 7.8a, b).
a b
Fig. 7.8 (a, b) After 6 months in treatment, lower esthetic brackets were bonded from the first
right molar to the left first molar
A control and pre-programmed mesiodistal enamel reduction were performed in

the lower arch to normalize the anterior and canine crowding.
A manual technique using abrasive metallic strips was recommended, especially
for the lower anterior teeth, to avoid gingival tissue damage (Fig. 7.9a, b).
a b
Fig. 7.9 (a, b) Results after a controlled stripping procedure in the lower arch
Case Study 1 139
Before the stripping is performed, it is important to know the thickness of the

enamel, the inter-root spaces, and the relation between the width of the root and the
shape of the crowns. Six sessions were necessary to complete the correction of the
crowded teeth.
For better control, it was advisable that the enamel reduction be performed
during several appointments (Fig. 7.10a, b).
As always, careful polishing of the stripped areas with composite strips is
highly recommended in addition to daily fluoride buccal rinses to enhance
remineralization.
a b
Fig. 7.10 (a, b) The normalization of the incisor and canine position is clearly visible
These are the results at the end of 22 months of treatment. The treatment
objectives were fully achieved. Overjet and overbite were normalized as well as the
lower anterior crowding (Fig. 7.11a, b).
a b
Fig. 7.11 (a, b) Final front photographs after 22 months of treatment

All the extraction spaces were closed and Class I right and left canine was
achieved. The occlusal plane was almost parallel to the gingival line. No more gin-
gival recessions were observed (Fig. 7.12a, b).
a b
Fig. 7.12 (a, b) Right and left views at the end of the treatment. Class I right and left canine was
achieved
For retention, a 0.0195 multistrand stainless steel lingual fixed retainer was
bonded from the right to the left canine in the upper and lower arches (Fig. 7.13a, b).
An upper nightguard was also recommended to reduce dental wear resulting
from bruxism.
a b
Fig. 7.13 (a, b) Upper and lower arches with fixed retention in place. All the extraction spaces
were closed
Case Study 1 141
Smile comparison pre- and post-treatment showed a wider smile despite the fact
that the first upper bicuspids had been extracted (Fig. 7.14a, b).
a b
Fig. 7.14 (a, b) Comparison pre- and postsmile photographs
A control 2 years later showed that the smile was improved and normal interden-
tal gingival papillae in the upper and lower arches were achieved (Fig. 7.15a, b).
a b
Fig. 7.15 (a, b) Control 2 years post-treatment

Class I canine and lateral occlusion were maintained along with normal gingivo-
periodontal tissues (Fig. 7.16a, b).
a b
Fig. 7.16 (a, b) Right and left photographs 2 years after treatment
The occlusal photographs confirmed the maintenance of the results (Fig. 7.17a, b).
It was recommended that the retention wires be used for a long time, especially in
the lower arch.
a b
Fig. 7.17 (a, b) Long-term control with the retention wires in place
Case Study 2 143
Case Study 2
The second patient is a 30-year-old woman who complained about the labial posi-
tion of the left upper canine and the left lateral incisor.
She had an unesthetic smile with the left lateral incisor in crossbite position. A non-
gummy smile was observed and the midlines were almost coincident (Fig. 7.18a, b).
a b
Fig. 7.18 (a, b) Pretreatment smile and front photograph
All the upper and lower first right and left molars had been extracted due to fail-
ures in previous endodontic treatments. Intraorally, there were no periodontal prob-
lems and the oral hygiene was good (Fig. 7.19a, b).
No signs of pain or clicking at the temporomandibular joints were present.
a b

The occlusal photographs confirmed the absence of the upper and lower first
molars. The upper right second molar was mesioinclined, and a porcelain crown on
the upper right second bicuspid was present (Fig. 7.20a, b). There was no space for
the canine between the upper left lateral incisor and the first bicuspid.
a b
Fig. 7.20 (a, b) Upper and lower arches where the absence of the four first molars was
confirmed
The panoramic Rx showed some asymmetry in the mandibular ramus height; the
four first molars and the third lower left molar were absent.
The lateral Rx confirmed that she was a dolichofacial patient (VERT 1.77) with
a very short mandibular corpus and a significant lower facial height (53)
(Fig. 7.21a, b).
a b

Case Study 2 145
2. Achieve Class I canine on the right and left side.
3. Close of the first absent molars spaces.
4. Improve overjet and overbite.
6 Achieve long-term stability.
Treatment Plan
Lingual brackets with 0.018 slot and bite plane were used (7th Generation Ormco).
After the alignment of the upper teeth (Respond 0.0155), closing the space of
the extracted left first molar was decided to regain space for the left upper canine
without losing the midline coincidence.
A TMA 0.016 wire was placed to begin the retraction process in conjunction
with an elastic chain from the second bicuspid to the second molar (Fig. 7.22a, b).
a b
Fig. 7.22 (a, b) Front and occlusal views during the beginning of the retraction procedure
When the space for the canine was almost achieved, a lingual bracket was bonded
indirectly, and a 0.016 TMA archwire with distal canine and mesio-molar bends
was placed to complete the alignment of the upper arch. A figure-of-eight ligature
between the anterior teeth was used to maintain their position (Fig. 7.23a, b).
a b
Fig. 7.23 (a, b) The canine was almost in place whereas the midline was coincident
In the next stage, lower lingual brackets were bonded to align and level the lower
arch (0.016 TMA).
To improve lateral occlusion, Class II elastics (1/8 medium) were recommended
(Fig. 7.24a, b).
a b
Fig. 7.24 (a, b) Class II elastics were recommended to improve occlusion

Case Study 2 147
Lateral views with Class II elastics in place, between the upper canines and the
lower second bicuspids (Fig. 7.25a, b).
a b
Fig. 7.25 (a, b) Class II elastics to improve occlusion
These were the results after 16 months in treatment. The upper canine was in place
and the midlines were still coincident. Some lower incisor gingival retraction occurred.
Changes in the position of the toothbrush were recommended (Fig. 7.26a, b).
a b
Fig. 7.26 (a, b) Front photographs after 16 months in treatment

Clear buttons on the labial side of the second lower molars were bonded to
improve lateral occlusion and close the remnant first lower molar spaces.
A 20 h per day use was necessary to obtain good results a slight gingival retrac-
tion of the upper left cuspid was visible (Fig. 7.27a, b).
a b
Fig. 7.27 (a, b) Right and left sides with Class II elastics to close the remnant lower absent molars
spaces
When the objectives of the upper arch were achieved, the maxillary lingual
brackets were removed. Metal buttons on the palatal surfaces of the canines were
bonded in order to continue using Class II elastics.
Final arches 0-0175 0.0175 were used for final detailing and better torque
control (Fig. 7.28a, b).
a b
Fig. 7.28 (a, b) Upper and lower arches after 20 months of treatment
Case Study 2 149
Results at the end of the active orthodontic lingual treatment. All the objectives
were fully achieved, and maximum esthetics was maintained during the whole treat-
ment period. The labial position of the left canine was totally corrected (Fig. 7.29a, b).
a b
Fig. 7.29 (a, b) Post-treatment front photographs
Class I canine was almost achieved and all the molar extraction spaces were
closed (Fig. 7.30a, b).
a b
Fig. 7.30 (a, b) All the molars extraction spaces were closed
Fixed retention wires at the upper and lower arches were recommended for a
long period of time in combination with an upper clear retainer for night use only
(Fig. 7.31a, b).
a b
Fig. 7.31 (a, b) Upper and lower fixed retention in place from upper and lower right first bicuspid
to left first bicuspid
The post-treatment panoramic radiograph confirmed that all the molar extraction
spaces were closed and no root resorption was present.
The lateral radiograph showed that only dental movements were performed
(Fig. 7.32a, b).
a b
Fig. 7.32 (a, b) Post-treatment panoramic and lateral radiograph

Case Study 2 151
Comparison of the front photographs pre- and post-treatment. The photographs

clearly showed the improvement of her smile (Fig. 7.33a, b).
a b
Fig. 7.33 (a, b) Comparison of the front smile pre- and postorthodontic treatment
This patient confirmed that it is totally possible to close the first molar extraction
space with lingual orthodontics (Fig. 7.34a, b).
a b
Fig. 7.34 (a, b) Pre- and postupper occlusal maxillary arch 2 years later
The patient was fully satisfied with the orthodontic results. No signs of temporo-
mandibular disorders were present. All the closed spaces were maintained
(Fig. 7.35a, b).
a b
Fig. 7.35 (a, b) Control 2 years later. The results were maintained or even improved
Case Study 3
The following patient was a 28-year-old patient that was sent to the office by his
dentist at that time in order to improve his marked deep overbite occlusion. Lingual
upper and lower brackets were suggested for esthetic reasons, taking into consider-
ation that this was going to be his third orthodontic treatment.
Irregular clicks without pain were audible in the temporomandibular joint.
A clear midline deviation was present and an evident uneven gingival line was
visible (Fig. 7.36a, b).
a b
Fig. 7.36 (a, b) Pretreatment front photographs

Case Study 3 153
The lateral photographs showed Class II canine and molar on the right side and
Class I on the left. The overbite was more evident in the anterior region and more on
the left side. The interincisal diastema got worse during the last 6 months (Fig. 7.37a, b).
a b
Fig. 7.37 (a, b) Lateral views before treatment
Looking at the upper occlusal arcade, an observable compression on the right

side was visible. No cavities were present on the upper and lower arches
(Fig. 7.38a, b).
a b
Fig. 7.38 (a, b) Upper and lower occlusal photographs. A pronounced asymmetry was evident on
the right side
The panoramic radiograph and the lateral radiograph confirmed the evident
asymmetry that was present. The different width and length of the ramus was evi-
dent (Fig. 7.39a).
The lower facial height (42), the position of the first molar, and the posterior
height of the occlusal plane were diminished (7 mm).
According to McNamara, the distance to point A was 6 mm and to point Pg 10 mm.
The length of the mandibular corpus was 7 mm less than normal (Fig. 7.39b).
a b
Fig. 7.39 (a, b) Pretreatment panoramic and lateral radiograph
The front radiograph clearly revealed that the amount of the asymmetry was not
only dental but also skeletal (Fig. 7.40a, b).
a b
Fig. 7.40 (a, b) Frontal Rx and smile where the asymmetry is evident
Case Study 3 155
3. Obtain Class I canine and molar.
4. Normalize occlusal plane.
5. Improve oral health.
Treatment Plan
Bearing in mind that it is important to first normalize the upper arch in the trans-
verse dimension, lingual 7th generation brackets (Ormco Corporation) were bonded
from the right to left first molar by indirect method in combination with a Ni-Ti-Cu
0.016 (Fig. 7.41a, b).
a b
Fig. 7.41 (a, b) Front and occlusal photographs after the lingual brackets were bonded
As a consequence of the anterior bite plane, a lateral open bite was visible.
The patient had to be instructed to eat soft meals during this period (Fig. 7.42a, b).
a b
Fig. 7.42 (a, b) Lateral views with lingual brackets with bite plane and a 0.016 Ni-Ti-Cu
archwire as a first arch
Three months later, the temporomandibular clicks had disappeared while alignment
was still taking place. The diastema was closed with a ligature wire and the same
Ni-Ti-Cu wire was in place (Fig. 7.43a, b).
a b
Fig. 7.43 (a, b) Frontal and occlusal photographs during the alignment procedure
Case Study 3 157
The use of the Ni-Ti-Cu wires permitted a slow and controlled tooth movement,
and as it was described before, this is the best way to move teeth with bone and not
through it. The changes in the shape of the upper arch were positive (Fig. 7.44a, b).
a b
Fig. 7.44 (a, b) The alignment and leveling of the upper arch was clearly observed
A significant leveling of the lateral areas and the normalization of the transverse
dimension was observed (Fig. 7.45a, b).
a b
Fig. 7.45 (a, b) Lateral views at this stage of the treatment

Brackets on the lower arch were bonded indirectly with a 0.016 Ni-Ti wire. An
open coil spring between the canines and the first bicuspids was placed with not
much activation.
In the upper arch, a 0.0175 0.0175 TMA archwire to better control torque was
indicated. Distal canine and mesiomolar compensation had to be included (Fig. 7.46a, b).
a b
Fig. 7.46 (a, b) Upper and lower occlusal view at the end of Phase I
To achieve Class I canine, elastics from the right upper canine to the second right
bicuspid were indicated (1/8 heavy) 20 h a day.
The deep overbite was almost corrected (Fig. 7.47a, b).
a b
Fig. 7.47 (a, b) Class II elastics to achieve Class I canine

Case Study 3 159
Since the second bicuspid was intruded, two esthetic buttons for another elastic
(1/8 heavy) was placed between it and the lower first molar (Fig. 7.48a, b).
a b
Fig. 7.48 (a, b) Esthetic composite buttons to normalize the upper second right bicuspid
To enhance lateral right occlusion, an esthetic button on the labial surface of the
canine was bonded for the use of Class II rubber bands (Fig. 7.49a, b).
a b
Fig. 7.49 (a, b) Right and left lateral view with clear buttons to improve occlusion
These were the results after 24 months of treatment. Almost all the treatment objec-
tives were achieved. The interincisal diastema was closed, overjet and overbite normal-
ized, midlines centered, and occlusal plane parallel to the gingival line (Fig. 7.50a, b).
a b
Fig. 7.50 (a, b) Post-treatment frontal photographs
On the lateral views, the same initial objectives were fulfilled: achieved Class I
canine and molar, normalized overjet and overbite, and the occlusal plane paralleled
to the gingival line (Fig. 7.51a, b).
a b
Fig. 7.51 (a, b) Post-treatment lateral views

Case Study 3 161
Regarding the retention plan, upper and lower fixed retention wires were
suggested in conjunction with an upper clear removable retainer for better control
of the transverse dimension and the deep overbite (Fig. 7.52a, b).
a b
Fig. 7.52 (a, b) Upper and lower fixed retention was recommended for a long period of time
Panoramic and lateral radiograph at the end of the treatment, 3 weeks before
debonding. No root resorption was visible in spite of all the dental movements that
were carried out.
The normalization of the deep overbite and the occlusal plane was evident.
The extraction of the upper third molars was advisable (Fig. 7.53a, b).
a b
Fig. 7.53 (a, b) Post-treatment panoramic and lateral radiograph

The improvement of the occlusion was clearly demonstrated when the compari-
son of the pre- and postsmile was done. No more black corridors and better incisor
torque was achieved (Fig. 7.54a, b).
a b
Fig. 7.54 (a, b) Pre- and postsmile photographs
When the pre- and post-treatment upper arch photos were compared, an important
change in the transversal shape was visible (Fig. 7.55a, b).
No more temporomandibular symptoms were present.
a b
Fig. 7.55 (a, b) Comparison of the upper arch pre- and postorthodontic treatment
Bibliography 163
In spite of the fact that he was a nongrowing patient, the normalization of the
Class I molar and canine was achieved after the correction of the mesioinclination
of the upper right first molar and the use of Class II elastics (Fig. 7.56a, b).
a b
Fig. 7.56 (a, b) Pre- and post right side
Conclusions
Judging from the final results, it is difficult to tell if these patients were treated
with labial or lingual brackets.
All types of malocclusions can be treated with lingual brackets no matter the
age of the patient and the type of initial problems.
Bibliography
Harfin J, Urea A. Ortodoncia lingual: procedimientos y aplicacin clinica. Argentina, Colombia,
Espaa, Mexico y Venezuela: Editorial Mdica Panamericana; 2010.
Finishing
8
The finishing process has to pursue a strict protocol, and there are some significant
differences in cases with or without extractions (Hilgers 1996).
It is important to remember that the leveling of the occlusal plane has to be
finished before all the extraction spaces were completely closed.
At this moment, it is advisable to recheck the position of the brackets to accom-
plish torque control (0.0175 0.0175 TMA or 0.016 022 SS archwire). Inter-
arch elastics could be used to improve anterior or lateral occlusion.
According to numerous studies, the last arch has to be in place during 816 weeks
before debonding permitting the recovering of the periodontal fibers, especially
when rotated teeth are present.
An individualized retention plan is the best choice for each patient. The length of
the retention has to be in accordance with the initial malocclusion, age of the patient,
amount of periodontal attachment, periodontal biotype, residual amount of growth,
etc. (Zachrisson and Artun 1979; Rummel et al. 1999).
The debonding protocol is as important as the bonding phase. The enamel has to
be protected for possible damage during all this process.
The brackets have to be removed with the last wire in place with a special plier
to avoid enamel cracks and the possibility of the patient swallowing a bracket dur-
ing the process (Fig. 8.1a, b).
a b
Fig. 8.1 (a, b) The brackets have to be removed with the last wire in place

DOI 10.1007/978-3-319-06832-9_8
166 8 Finishing
Insofar, it is better to break the adhesive bond in the adhesive-bracket interface

(Fig. 8.2a, b).
a b
Fig. 8.2 (a, b) Composite remains over the palatal surface of the teeth
The final procedure is the removal of the adhesive remnants from the tooth
surfaces, avoiding enamel iatrogenic damage (Oliver and Griffiths 1992).
The most common removal technique uses a low-speed handpiece with a round
or barrel tungsten carbide bur. It is recommendable not to use water for better con-
trast between the adhesive and the enamel (Fig. 8.3a, b).
a b
Fig. 8.3 (a, b) Burs with a low-speed handpiece to remove adhesive remnants
8 Finishing 167
After that, a careful enamel polishing is necessary, avoiding gingival tissue

bleeding (Fig. 8.4).
Fig. 8.4 Different types of burs to polish the enamel
It is highly suggested that the retention wire has to be bonded at the same moment
the brackets were removed.
The same procedure has to be made in the lower arch. The same removal plier as
in the upper arch is used in the lower arch (Fig.8.5a, b).
a b
Fig. 8.5 (a, b) Debonding brackets in the lower arch

168 8 Finishing
After a careful enamel polishing, 37 % etching gel acid for 30 was placed with
an applicator brush, avoiding contact with the gingival tissues. Rinse thoroughly
with air-water spray and suction using high-speed evacuator.
It is important to maintain a completely dry field not allowing the patient to con-
tact the etched enamel with saliva.
After that, the enamel has to be dried with clean air. The result is an enamel with
a frosty appearance. A small amount of sealant with a small brush has to be placed
on the etching enamel surface (Fig. 8.6a, b).
a b
Fig. 8.6 (a, b) Frosty appearance of the enamel before sealant is placed
A 0.0195 dead soft Respond wire (Ormco) is highly recommended as a lingual

or palatal retainer. It is easy to adapt to the lingual or palatal surfaces with a light-
cure flow composite (Fig. 8.7a, b).
a b
Fig. 8.7 (a, b) A dead soft Respond wire was bonded with flow adhesive
8 Finishing 169
It is highly advisable to remove the composite excess before light-curing the

surface. After that, fluoride topics, varnish, or fluoride mouth rinse is suggested.
The patient can drink or eat right after (Fig. 8.8a, b).
a b
Fig. 8.8 (a, b) Upper and lower retention wire in place
Bonded lingual retainers are highly effective and reliable in maintaining the
alignment of severely crowded teeth with the benefits of good esthetics, comfort,
easy to fabricate, and low cost.
After 1012 weeks later than the appliances were removed, occlusal points
should be controlled to avoid premature interferences that could cause functional
deviations.
It is important to consider dental and skeletal stability in all three dimensions:
vertical, sagittal, and transverse. In each one of them, the recurrence of the initial
problem is a sign of instability of the orthodontic treatment (Geron 2006). An indi-
vidualized and exhaustive diagnosis and treatment plan is the only way to avoid
difficulties during the finishing process.
After bonding the retainers, there are other considerations to keep in mind.
Among them there is one that is very important for the patient: cosmetic
appearance.
As Dr. Vincent Kokich said, we have to consider facial and dental esthetics when
setting treatment objectives.
It is necessary to visualize where the treatment is headed from the esthetic point
of view, especially with peg-shaped lateral incisors or when lateral incisor agenesis
is present.
One of the most important esthetic considerations is the size and proportion of
the anterior teeth.
The width of the upper central incisors can vary from 8.3 to 9.3 mm and its
length from 10.3 to 11.2 mm.
The proportion between the width and the length is approximately 80 %, and the
same proportion is taken into account for the upper lateral incisors.
170 8 Finishing
The width of the teeth is normally maintained without significant changes; how-
ever, where the length is concerned, the following formula can be applied to deter-
mine the ideal proportion (Fig. 8.9a, b):
width 100
Length =
80
Length = width 1.25
a b
Fig. 8.9 (a, b) Ideal tooth proportions (Courtesy Dr. Juan Cruz Gallego)
In relation to the width of the lateral incisors, it should be 66 % of the width of

the central incisors.
All this information should be gathered before the treatment plan is made.
Provisional restorations should be prepared before orthodontic treatment starts
and final ones after the orthodontic treatment ends.
The normalization of the periodontal tissues after the orthodontic treatment has
to be another important goal.
It is difficult to place the brackets in the correct position when the anterior teeth
are shorter due to passive eruption of the gingival tissues.
8 Finishing 171
A gingivoplastic procedure is recommended before the orthodontic treatment

begins in order to normalize the length of the anterior teeth (Fig. 8.10ac).
a b
Fig. 8.10 (ac) Before, during, and after the gingivoplastic procedure (Courtesy Dr. Juan Cruz
Gallego)
When the periodontal biotype is thin, some dehiscences would be present during
the treatment (Fig. 8.11a, b).
a b
Fig. 8.11 (a, b) Pre- and during orthodontic treatment, the dehiscence on the right canine is clear
(Courtesy Dr. Juan Cruz Gallego)
172 8 Finishing
In some cases, a post-orthodontic treatment gingival graft is required to normal-

ize the height of the gingival margin (Fig. 8.12a, b).
a b
Fig. 8.12 (a, b) During and 4 weeks after the gingival graft (Courtesy Dr. Juan Cruz Gallego)
To achieve a highly esthetic goal, the reconstruction of a narrow lateral incisor is

required. Dental porcelain veneers are the best solute (Fig. 8.13a, b).
a b
Fig. 8.13 (a, b) Pre- and post-reconstruction with a porcelain veneer of the right upper lateral
incisor to obtain ideal tooth proportion (Courtesy Dr. Juan Cruz Gallego)
Conclusions
The initial correct position of the brackets is fundamental to obtain a correct
alignment of the gingival margin and bone height, especially in adult patients.
Otherwise, some bends have to be performed to intrude or extrude the teeth to
achieve a correct smile.
It takes a great deal of time and effort to correct unwanted side effects in
lingual treatment. It is much easier to avoid than to correct the mistakes (Geron
2006). The reposition of the anterior brackets at the end of Phase I and Phase II
is always recommendable to minimize wire bending during the finishing
process.
Bibliography 173
Full engagement of the last archwire in the bracket slot is necessary to express
the right torque at the beginning of Phase III to allow full expression of the pre-
scription and in this way reduce treatment time.
It is important to remember that the dentition will continue to change little
by little even during the retention period and the relapse of the mandibular
anterior segment during the postretention period is one of the most predictable.
Long period of time of retention is one of the best suggestions in all these
patients.
Bibliography
Geron S. Finishing with lingual appliances, problems and solutions. Semin Orthod.
2006;12:191202.
Hilgers JJ. Functional finishing. The concept, the tools, the techniques. Clin Impressions.
1996;5:813.
Oliver RG, Griffiths J. Different techniques of residual composite removal following debonding:
time taking and surface enamel appearance. Br J Orthod. 1992;19:1317.
Rummel V, Weichmann D, Sachdeva RC. Precision finishing in lingual orthodontics. J Clin
Orthod. 1999;33:10113.
Zachrisson BU, Artun J. Enamel surface appearance after various debonding techniques. Am J
Orthod. 1979;75:12137.
Summary and Outlook
9
Lingual orthodontics is here to stay.
An increasing number of adults, adolescents, and children consider it the only

alternative to orthodontic treatment. They dont settle for the professional opinion
of a single doctor who might not recommend it for their particular treatment. Quite
the contrary, keeping their objective in mind, they tend to seek out doctors who use
this technique.
That is why this treatment option should be available to patients in all offices. It
is possible to assure that the results obtained by using lingual orthodontics is as
good as those obtained with labial orthodontics and that once treatment has ended,
it is difficult to determine what type of technique was used (Harfin and Urea 2010).
Since the objective of this book is to provide a simple and efficient way to treat
patients with lingual brackets without depending on expensive and outside labora-
tories, step-by-step procedures are described in each chapter (Harfin and Urea
2010; Hiro 2011).
Today adult patients are looking for more and more invisible orthodontics to treat
not only simple but severe malocclusions too, no matter the amount of periodontal
attachment that was present.
As the orthodontist is the one who decides the best treatment plan for the patient,
he/she determines the best position and inclination of the teeth.
It is totally accepted that the indirect method not only increases safety and
reduces chair time but also improves efficiency and efficacy.
The degree of speech problems or other signs of discomfort during the first week
is bearable. After that, the patient doesnt have any more inconveniences during the
rest of the treatment.
In some cases, the lingual technique can even be a better choice to labial ortho-
dontics, not only because it is totally invisible but also because it may present
greater advantages from the biomechanical point of view (deep overbite, diaste-
mata, etc.) (Romano 2011).

DOI 10.1007/978-3-319-06832-9_9
176 9 Summary and Outlook
To achieve optimum results in a reasonable period of time, the exact positioning

of the brackets is mandatory.
Future ????
In the future, lingual orthodontic treatment would be considered a routine treat-
ment technique.
The ideal bracket has to be designed taking into account the following features:
1. Small dimensions, reduced thickness, and mesiodistal dimension to improve

patients comfort with minimum speech and mastication discomfort
2. Large bonding surface for bracket stability
3. Large interbracket distance
4. Smooth surfaces
5. Easy archwire insertion
6. Easy ligation
7. Easy hygiene maintenance
At the present time, totally individualized brackets and wires are available, but
until now, they are a lot more expensive (Weichmann et al. 2008).
New alloys of wire with controlled memory are also welcome.
The use of smaller brackets improves patient comfort, with less speech distur-
bance and better oral hygiene possibilities.
The combination of lingual brackets and the use of micro-implants for temporary
orthodontic anchorage is an effective way to achieve absolute anchorage. When
reciprocal or minimal anchorage is needed, other classic methods can be used
(Nance button, transpalatal bar, etc.).
When deciding on the treatment and retention plan, it is very important to take
the relationship between the upper lip, the gingival line, and the smile line into
account.
Nowadays, there is an increased tendency to investigate accelerating methods for
tooth movement (Liou and Huang 1998). Among them piezocision technique is
considered one of the most controlled.
But the most interesting and important aspect will be the new advances in the
genetic field and how orthodontic movement can be improved and accelerated by
managing the osseous turnover. Some clinical investigations have demonstrated that
this hypothesis is totally possible nowadays. The future will be based in these new,
ambitious, and incredible paths, and the results are not far (Nimeri et al. 2013).
Today, it is possible to confirm that the treatment results obtained with lingual
appliance are similar to the results achieved with labial brackets (Harfin and Urea
2010).
Lingual orthodontic is the only invisible treatment; also it is safer for labial
enamel too and makes an important contribution to patient quality of life.
Long-term retention is the only way to maintain the results that were achieved as
minor changes after orthodontic treatment seem to be the norm and should be
accepted. As it was demonstrated, there is no positive relation between the types of
Bibliography 177
malocclusions and post-treatment changes but the relapse in the mandibular anterior
segments is one of the most predictable results.
The cases presented in this book clearly demonstrated that it is possible to
achieve excellent results with facial harmony and a pleasing profile by using brack-
ets placed on the lingual or palatal surfaces of the teeth. Since no special equipment
is needed, all the orthodontists can easily manage this technique in their offices.
It is important to take into account that correct positioning of maxillary and man-
dibular incisors is vital to optimum function, stability, and esthetics.
Excellence in orthodontic lingual treatment demands an exhaustive diagnosis,
treatment, anchorage, and retention plan in concordance with an organized
biomechanics.
Bibliography
Hiro T. Indirect bonded technique in lingual orthodontics: the Hiro system. In: Romano R, editor.
Lingual and esthetic orthodontics. London: Quintessence; 2011. p. 23954.
Liou EJ, Huang CS. Rapid canine retraction through distraction of the periodontal ligament. Am J
Orthod Dentofacial Orthop. 1998;114:37282.
Nimeri G, Kau C, Abou-Kheir N, Corona R. Acceleration of tooth movement during orthodontic
treatment- a frontier in orthodontics. Prog Orthod. 2013;14:429.
Romano R. Future of the lingual orthodontics technique. In: Romano R, editor. Lingual and
esthetic orthodontics. London: Quintessence; 2011. p. 6814.
Weichmann D, Gerss J, Stamm T, Hohoff A. Prediction of oral discomfort and dysfunction in lin-
gual orthodontics. A preliminary report. Am J Orthod Dentofacial Orthop. 2008;133:35964.
Index
A partial canine retraction, 2021

Anchorage control phase I, 1617
anterior torque loss, 31 phase II, 2836
classification, 28 phase III, 44
Mathieu thin-end plier, 34 quad helix use, in lingual orthodontics, 19
micro-implants, 30 rotated teeth correction, 2328
Nance button, 28, 29 silicone impression, 13
occlusal plane align and torque transverse control of position,
expression, 31 upper first molars, 4344
omega loop, 35, 36 Brackets
posterior lateral sectional alignment phase, 136
alignment, 33 debonding, 167
pre-extraction posterior front and occlusal photographs, 155
alignment, 32 ideal features, 176
reverse curves, 32 inserts with elastomeric ligatures, 9
sliding mechanics retraction, 33 lateral views with, 156
Anterior crowding. See Lower anterior removal, finishing process, 165
crowding reposition, lingual, 3943
Brush, low-speed handpiece, 12
B
Biomechanics C
anchorage control, 2836 Cephalometric evaluation, upper incisors
coil springs use, 2123 proclination, 135
elastics use, 3739 Class I canine and lateral occlusion, 142
indirect bonding Class II elastics
brush, low-speed handpiece, 12 to achieve class I canine, 158
cheek, lip, and tongue retractors, 12 occlusion improvement, 147
dry air syringe, 13 pendulum usage,
individual transfer cap, 14 lingual appliances, 104, 105
light-cure bonding agent adhesive, 13 pre-and post right side, 163
molar transferring cap, 14 remnant lower absent
palatal and lingual tooth anatomy, 11 molars spaces, 148
plication, 13 Coil springs use, 2123
laboratory procedures, 311 Crowding
ligation approaches, 1415 deep overbite, 61
lingual bracket reposition, 3943 lower anterior (see Lower anterior
lingual utility arch, 1718 crowding)

DOI 10.1007/978-3-319-06832-9
180 Index
D porcelain veneer, pre-and

Deep overbite post-reconstruction, 172
Bolton-positive discrepancy, 72 teeth width, 170
central incisors, 68
cephalometric analysis, 62
class II elastics, 71 G
clinical examination, 60 Gingivoplastic procedure, 171
etiology, 59
frontal and occlusal view, 70
indirect bonding, 62 I
interincisal diastema, 71 Impacted canines
photographs brackets, 123
pretreatment buccal front, 60 distal canine and mesio-molar bends, 124
pretreatment panoramic, 62 front and occlusal photographs, 127
positive discrepancy, 68 gingivo-periodontal tissues, 126
posterior teeth, extrusion, 60 lingual ballista, 121
pre-and post-Ricketts analysis, 67 Ni-Ti coil spring, 128
pre-and post-treatment smile, 68, 72 occlusal photograph and radiograph, 122
prevalence, 59 pretreatment panoramic
treatment and occlusal radiograph, 126
class I molar, lateral views, 64 prevalence, 119
lateral views at beginning, 61 resorption, 119
Ni-Ti 0.013'' archwire, 63 simple and controlled mechanics, 130
Ni-Ti-Cu archwire, 63 smile and the panoramic radiograph, 125
objectives, 62, 66, 70 surgical protocol, 119
optimal buccal occlusion, 65 temporary crown, 123
protocol, 59 treatment, 119
radiographs, panoramic and lateral, 67 wire ligature, 121
TMA archwire, 64 Impression. See Silicone impression
upper and lower arches, 65 Indirect bonding, biomechanics
upper and lower fixed retention, 66 brush, low-speed handpiece, 12
cheek, lip, and tongue retractors, 12
dry air syringe, 13
E individual transfer cap, 14
Elastics light-cure bonding agent adhesive, 13
class II (see Class II elastics) molar transferring cap, 14
intermaxillary, 112 palatal and lingual tooth anatomy, 11
open bite malocclusions use plication, 13
chains, 83
at night, 94
use, 3739 L
Esthetic composite buttons, 159 Labial/lingual brackets. See Brackets
Lingual utility arch, 1718
Lower anterior crowding
F class I canine and molar, 52
Finishing process diamond single-side strips, 48, 50
adhesive remnants removal, 166 enamel reduction, 48
bonded lingual retainers, 169 etiology, 47
brackets removal, 165 first molar, mesio-rotated, 52
composite remains, 166 lingual brackets
debonding brackets, 167 placement, 50
enamel polishing, 167 removal, 51
gingival graft, 172 7th generation, 53, 56
gingivoplastic procedure, 171 lower anterior stripping, 53
periodontal biotype, 171 maxillary arch, 52
Index 181
photographs pre-and post front photographs, 85

beginning of treatment, 49 pre-and post lateral radiographs, 96
overbite, 51 pre-and post-treatment upper
post-treatment front, 54 occlusal arch, 86
pretreatment front and lower occlusal, 48 pre-treatment front and upper occlusal, 76
upper and lower arches, 49 pre-treatment panoramic and lateral
primary group, 47 radiographs, 80
retention wire, upper and lower arches, 55 pre-vs. post lateral radiographs, 79
secondary group, 47 remnant spaces, 94
stripping, 48 retention protocol, 76
TMA archwire, 57 retention wires in place, 85
treatment sliding mechanics, 82
1st phase of, 54 soft tissue evaluation, 75
lateral views at end of, 55 TMA archwire, 81, 84
objectives, 53 transpalatal arch, 92
treatment
biomechanics, 75
M objectives, 81, 90
Mathieu thin-end plier, 34 plan, 90
Micro-implants, 30 speech-pathology, 90
Molars extraction spaces, 149 upper and lower occlusal view, 91
upper occlusal arch, 89
Overbite. See Deep overbite
N
Nance button, 28
P
Partial canine retraction, 2021
O Pendulum usage, lingual appliances
Omega loop, 35 bicuspid distalization, 103
Open bite malocclusions, nongrowing patients class I canine, 109, 114
anterior lingual bracket, 77 class II canine, 109
archwire, 95 class II elastics, 104, 105
cephalometric tracings, superimposition, class I molars, 104, 114
97 class II molars, 109
elastics use distalization, second upper bicuspids, 111
chains, 83 intermaxillary elastics, 112
at night, 94 Nance button appliance, 100
esthetic lateral buttons, 83 non-extraction treatment modalities, 99
fixed retention wire, 78 normalization, 99
lateral crossbite, anterior open bite, 80 occlusal photographs, 109
lateral occlusion improvement, 93 panoramic Rx, 102
lateral views, 76 post-treatment lateral views, 114
lip closure, 96 post-treatment right and left side, 106
lower arch, 89 pre-and post-Ricketts superpositions, 115
Nance button, 92 pre-and postsmile photographs, 107
night dental plaque, 86 pre-and post-treatment Rickettss
overjet and overbite, 78, 93 analysis, 108
photographs pre-treatment front and smile, 101
before and after orthodontic retention wires, 116
treatment, 86 stainless steel lingual fixed retainer, 106
midline deviation in front, 88 transpalatal arch, 112
musculature tension, 87 treatment
pretreatment front and occlusal, 79 objectives, 103, 110
pretreatment lateral views, 88 results after 2 and 4 months, 103
at rest position, 87 upper and lower arcades, 102
182 Index
Q mixing, 2
Quad helix use, in lingual orthodontics, 19 oral hygiene, 1
plaster models, 4
pre-and post-extra anterior torque, 11
R pre-and post-second-phase, 2
Retraction procedure, 145 Ricketts brackets, 10
Rotated teeth correction, 2328 setup cast model, 5
silicone spray application, 8
softened wax, 7
S vestibular plaster contention, 8
Silicone impression Sliding mechanics, 137
acrylic distal keys in place, 10 Stripping procedure, 139
adhesion, 1
densita gypsum rock, 4
with dental wax, 5 T
deocclusal plane control, 6 Tooth proportions, 170
dowel pins in place, 3
final alignment, 7
ideal lingual chart plate, 8 V
malocclusion model, 6 Vestibular plaster contention, 8

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Achieving Clinical

Achieving Clinical Success

ISBN 978-3-319-06831-2 ISBN 978-3-319-06832-9 (eBook)

Library of Congress Control Number: 2014952676

Springer International Publishing Switzerland 2015

Printed on acid-free paper

Springer is part of Springer Science+Business Media (www.springer.com)

God, for blessing me once again ...

Buenos Aires, Argentina Julia Harfin

Miyawaki S, Yasuhara M, Koh Y. Disconfort caused by bonded lingual orthodontic appliances in

4 Efficient Treatment of Open Bite in Nongrowing Patients. . . . . . . . . . 75

How to Take the Silicone Impression

Springer International Publishing Switzerland 2015 1

It should be correctly extended on the tray in order to obtain a good surface

Fig. 1.3 (a, b) Pre- and post-second-phase silicone impression

It is highly recommended to disinfect the silicone impression after taking it and

Fig. 1.6 (a, b) Models with densita gypsum rock

Fig. 1.10 (a, b) Initial malocclusion with numbered teeth

Lateral views to control de occlusal plane (Fig. 1.11a, b).

Fig. 1.11 (a, b) Numbered teeth in the lateral views

Fig. 1.13 (a, b) Final alignment

Fig. 1.14 (a, b) Ideal lingual chart plate

Fig. 1.15 (a, b) Silicone spray application

Fig. 1.16 (a, b) Vestibular plaster contention

Fig. 1.17 (a, b) Bracket inserts with elastomeric ligatures

Fig. 1.18 (a, b) For better control, a tweed plier is recommended

Fig. 1.20 (a, b) Acrylic distal keys in place

Fig. 1.22 (a, b) Pre- and post-extra anterior torque

Fig. 1.24 (a, b) A low-speed handpiece with a cleansing brush is recommended

Fig. 1.25 Cheek, lip, and

Fig. 1.28 (a, b) Light-cure bonding agent adhesive in place

Fig. 1.29 (a, b) Molar transferring cap in place

Lingual Utility Arch

Fig. 1.36 (a, b) Lower lingual utility arches

Fig. 1.37 (a, b) Lower utility arch in place

Fig. 1.39 (a, b) The two arches are clearly visible

Use of Quad Helix in Lingual Orthodontics

Fig. 1.42 (a, b) During and after extraction sliding mechanics

Partial Canine Retraction

Fig. 1.43 Partial canine

The following patient is a clear example.

Fig. 1.45 (a, b) Six and nine months in treatment

Use of Coil Springs

The same procedure can be used in the lower arch.

How to Correct Rotated Teeth

Fig. 1.52 (a, b) Elastomeric chain to initiate the Scott ligature

Fig. 1.53 (a, b) A Mathieu plier is useful to perform this ligature

As was described before, it is necessary to have the correct amount of space to

Fig. 1.57 (a, b) Initial steps of the Scott ligature

Fig. 1.60 (a, b) Final and fixed retention wire in place

Anchorage control is one of the most important chapters in orthodontic

The use of micro-implants as a noncompliance method is very advisable in

Fig. 1.63 (a, b) Micro-implants used as maximum anchorage

As was suggested before, it is necessary to add 510 of positive torque to the

Fig. 1.66 (a, b) Loss of anterior torque

Transversal bowing effect is the consequence when molars move lingually

Fig. 1.67 (a, b) Reverse curves expressed in a SS 0.016 0.022 archwire.

It is advisable to align lingual posterior segments (severe Class II Div I) before

When it is necessary to improve the transversal width, the canines have to be

Fig. 1.69 (a, b) Posterior lateral sectional alignment

Fig. 1.71 (a, b) A Mathieu thin-end plier is highly recommended

When en masse retraction is proposed, different types of loop figures could be

Fig. 1.75 (a, b) Final design of the omega loop

Fig. 1.76 (a, b) Closer view of the omega loop