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Dr.

Varun Grover

INDIAN DENTAL ACADEMY

Leader in continuing dental education
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Introduction
Goals of orthodontic treatment



Desire for esthetics during
treatment

Lingual orthodontics


End of treatment
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Search for absolute esthetics
Advancement in orthodontics

Pinching of the bands
Direct bonding (Miura 1971)
Plastic and ceramic brackets
Lingual brackets
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Search for absolute esthetics
Bands on all teeth
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Search for absolute esthetics
Metallic display
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Search for absolute esthetics
Ceramic brackets relatively esthetic
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Search for absolute esthetics
Lingual brackets
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Search for absolute esthetics
Good fortune of orthodontist

Reduced cost
Lower arch judge the progress
Reduced demands on the practitioner
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Historic perspective
John Farrar lingual removable arch (1889)

Mershon LRA with finger springs

Owen Oliver Labiolingual app

Crozat app


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Historic perspective
Nance button
TPA Robert Goshgarian
Lingual arch - Wilson
Note supplement labial orthodontics
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LO As a complete system
Vision of 2 key innovators

Craven Kurz USA

Kinya Fujita Japan
Kanagawa uni.

1970s
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LO As a complete system
Fujita system -1971
Advantages
Lip injury
Lip relation
Retention
Little anchorage loss
Brackets placed close to the functional line for forces
to pass through C res.
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LO As a complete system
Fujita system -1971
Disadvantages






AJO 1979 LO with Mushroom shaped archwires








Longer duration
Speech difficulties
Initial discomfort
Oral hygiene
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LO As a complete system
Key features Fujita system
Slots facing occlusally

Easy insertion and removal
Prevents deformation
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LO As a complete system
Grooves for insertion of lockpins




Auxilliary grooves
Mesiodistally
Occlusogingivally
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LO As a complete system
Multiple slots Less publicized
Ant. And Pm bracket 3 slots



Molar bracket 5 slots
Occlusal
Lingual
vertical
1 occlusal
2 lingual
2 vertical
Tandem wire mechanics
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LO As a complete system
Do lingual appliances hampers speech???

Sample 1 patient

Class I crowding
All 4s extraction

Pronunciation of vowels
Real time third octave analyzer

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LO As a complete system
A and O no effect

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LO As a complete system
I, E, U disturbed on 1
st

and 4
th
day
Normal by 6
th
day

S, T, R and L affected
Consonants were not
studied

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Craven kurz
Ormco
1976 introduced lingual app
Slots facing palatally
Worked as a part of LTF (1990)
Scholz Gorman
Kelly Alexander
Smith Artun
Greekmore




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Craven kurz
1976 1
st
generation of
lingual brackets


1990 7
th
generation
Larger profile
Crude prescription
Low profile
Refined prescription
Mx bite plane heart shaped, smaller hooks
Inc width of Pm brackets
Variety of molar brackets
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Craven kurz
Slot size 018
Greatest innovation



Shearing forces





Addition of bite plane
Compressive forces
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Lingual brackets
Mx anterior brackets

Built in bite plane
Propping open the bite
Adv in deep bite cases
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Lingual brackets
Mand anterior brackets
Ball hook extends away from the tissue
Ease in maintaining oral hygiene
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Lingual brackets
Bicuspid brackets - wider
Better rotational and tip control
More uniform interbracket width
Ball hooks shortened and flattened

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Lingual brackets
Molar brackets variety
Twin bracket
recommended when both 1
st
and 2
nd
molars are
bonded
Twin bracket with auxiliary tube



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Lingual brackets
Hinge cap
Latest
Ideal attachment for terminal tooth
Hinge cap tool

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Lingual brackets
Terminal tube
Used initially
Crown height is less
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Lingual instruments
Lingual utility plier
Ligature cutter
Curved mosquito hemostat
Small distal end cutter
Lingual bracket remover
Hinge cap opening tool
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Lingual Begg brackets
Fujita and Craven kurz




Stephen Paige 1982
Begg appliance suits well to LO
Edgewise slot
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Lingual Begg brackets
Vertical slot facing occlusally

Use of round arch wires

No built in tip and torque

TP (256 500) labial Begg bracket

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Lingual Begg brackets
Anatomic considerations



Interbracket distance precise measurement of the
arch wires
Difficult to position the bracket
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Lingual Begg brackets
Low profile lingual Begg bracket




Plastic buttons on labial surfaces assist
lingual app
Difficult to close the open bite
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Lingual Begg brackets
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Lingual Begg brackets
Lockpins softer and thinner (014)

Seated using a two hand instrument
Wire tucker

Weingart plier
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Lingual Begg mechanics
Low angle cases favorable md rotation
High angle cases
Smith (1986 )- HPHG
Cash and Blackwood (1991) JJ
Jenner (1995) Post bite plane
Convenient surface for mastication
Prevents molar extrusion
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Lingual Begg mechanics
Lingual archforms Mushroom shaped
Key hole shaped
Bicuspid offset
Molar offset
Anchor bends
Distal ends
Elastics

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Lingual Begg mechanics
Stage 1 archwires
No crowding - 016ss

Addition of vertical loops
Smaller diameter archwires

Niti or Cu Niti wires
Elastics stiffer wires

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Lingual Begg mechanics
Stage II archwires 018, 020
Stage III archwires 020
Torquing auxiliaries
Uprighting springs
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Lingual Begg mechanics
Lingual root torque for upper incisors

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Lingual Begg mechanics
Labial root torque of upper lateral incisors




Lingual root torque of the canines
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Lingual Begg mechanics
Uprighting springs
Stage III Mesiodistal root movement
Braking mechanics stage II
010 mini springs
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Conceal system
Thomas Creekmore (AJODO 1989)
Unitek, Monrovia, California
Advantages
Facial tooth surfaces are not damaged
Facial gingival tissues health
The position of the teeth can be precisely seen
Drape of the lips not distorted
invisible
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Conceal system
An acceptable LOA must include following key elements

Align
Apparatus to position the brackets precisely


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Conceal system
Accurate indirect bonding system
Preformed arches
Specifically designed pliers
Torquing keys
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Conceal system
Slots opens occlusally

The first 1mm of the molar tube
opens to the occlusal aspect

Direct guidance for insertion

Easier to insert stiffer archwires
Eliminates the need of double over
ties

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Conceal system
Design of Pm and molar bracket
Occlusal tie wings projecting mesially and distally
Mesial and distal undercuts II base of the slot
Changes the direction of ligature pull 90

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Conceal system
Conceal brackets are designed around the
Unitwin bracket
Centered slot concept
Single bracket without tie wings
Centre of a 0.045 inch twin bracket
Maximum interbracket distance for optimum tip and torque
Twin tie wings rotational control



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Conceal system
Each conceal bracket has 3 different slot widths
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Conceal system
Tip control in an occlusally inserting system is
analogous to rotational control in labial system

Rotational control length of the lever arm 0.100
inch
Slot width 0.100 inch
Excellent control in the tipping plane

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Conceal system
The width of the slot for rotation 0.070 inch

Analogous to tip control in the labial system

Torque control is same for both the systems

Width of the slot for torque 0.035 inch

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Conceal system
Play
Maximum arch wire size
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Conceal system slot machine
Lingual surfaces irregular
Labiolingual thickness
Slot machine
Holds the lingual bracket by its slot, which is oriented
to the labial surface of each tooth for-
Torque, tip, rotation, height and labiolingual thickness
Bracket is bonded on the model gap is filled
Customized base

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Patient selection
Adults

Missing teeth
Complex restorative needs
Periodontal problems

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Patient selection
Possible speech difficulty 2 to 4 wks

Absolute need for perfect speech

Tongue irritation

Opening up of the spaces

Oral hygiene considerations

Initial weight loss
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Patient selection
Deep bite cases are ideal for LO
Short clinical crown height relative CI
Initial practitioners
Non Xn
Deep bite
Mild crowding
Upper palatal lower labial app
Low anchorage demands
Unilateral Xn cases
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Patient selection
Deep bite Vs

Brachycephalic
Euryprosopic
Bite plane effect
Favorable Md rotation
Open bite

Dolichocephic
Leptoprosopic
Difficult cases
Cross elatics

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Patient selection
Biomechanical differences






For normally inclined or proclined upper incisors,
intrusive forces for lingual app are closer to Cres
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Patient selection
For retroclined anteriors
Advancing loops in initial archwires
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Patient selection
Effects of vertical extrusive forces
Labial appliance extrusion



Lingual app incisors are inclined more than 20 to
the occlusal plane
Labial root torque
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Patient selection
Effects in antero-posterior relation
Lingual appliances
Vertical opening
Md rotation
Induce Class II tendency
Vertical bowing effect
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Patient selection
Contraindications

Short clinical crowns
Unresolved periodontal problems
Mutilated posterior occlusion
High angle cases
Severe class II discrepancy with acute TMJ problems
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Patient selection
Effects in transverse dimension

LA expansive nature coupled by posterior
disclusion

Mesiobuccal molar rotation space closure

Transverse bowing effect

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Bracket placement
Indirect bonding
Why not direct bonding???




Customized resin beneath the brackets
Access
Irregular lingual surface
Variation in lingual tooth morphology

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Bracket placement
Methods of bonding

TARG Torque Angulation Reference Guide
CLASS Custom Lingual Appliance Set up Service
Fillion LIBS
Slot machine
Hiro system
Ray set system
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Bracket placement - CLASS
Scott huge
Ideal set up is created
Brackets placed
All planes of space considered
Custom bracket bases
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Bracket placement - CLASS
Brackets transferred to the original cast
Another indirect bonding tray is fabricated
Ideal set up patients motivation
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Bracket placement - CLASS
Steps

Precise impressions
Wax bite
Articulate the casts
Fill the prescription
I mmobilization of the teeth is a must
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Bracket placement - CLASS
Prescription form
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Bracket placement - CLASS
Ideal set up
Teeth act as reference
2
nd
molars and single incisor in each arch
Class I canine and molar
Establish adequate tip
Torque
Eliminate rotations
Tight contacts
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Bracket placement - CLASS
Filling the prescription
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Bracket placement - CLASS
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Bracket placement - CLASS
Transfer trays
Sectioning of the trays

Preference Vinyl
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Bracket placement - CLASS
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Bracket placement - CLASS
Overbite
Ideal
Increased
Decreased
Overjet
Ideal
Increased
Decreased
Lower occlusal plane
Flat
Maintain
Deep
Arch width
Maintain
Widen
Constrict
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Bracket placement - CLASS
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Bracket placement - TARG
Dev by Ormco, 1984

Bracket placed with respect to horizontal reference plane

Labial reference gauge to orient the bracket

The orientation allows preprogramming


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Bracket placement - TARG
Advantages
Accurate and quantified 2 dimensional system
Accurate positioning of bracket without cutting the
tooth and placing it in wax

Disadvantages
Labiolingual thickness not considered

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Bracket placement - BEST
Bonding with Equalized Specific Thickness

Fillion, 1987

Overcomes the disadvantage of TARG
A caliper is added

Direct working on the malocclusion cast
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Bracket placement Hiro system
Modified CLASS technique
Introduced by HIRO
Improved by Takemoto and Scuzzo

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Clinical bonding
Lingual side of the arch
Moisture contamination
Calculus deposition
Pre bonding scaling
Use of antisailogouges
Probanthine 15 mg 45 min prior to bonding
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Clinical bonding
If it is desirable to bond one arch
Mandibular arch
Special considerations
Porcelain restoration
Presence of aluminium HF acid
Composite bondable surface
Gold crowns
Large amalgam fillings
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Clinical bonding
Bonding materials

2 part sealant Maxi cure

Filled paste EXCEL, Reliance orthodontic product

Light cure adhesives

Bracket side tooth side adhesive
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Clinical bonding
Steps
Isolation
Etching
10 min before bonding, apply conditioner on exposed
adhesive material on bracket base
Mix the bonding material
Place the trays
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Thank you

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