Figure 1. This patient is a great example of a moderately complex case that lends itself to lingual treatment.

Figure 1. This patient is a great example of a moderately complex case that lends itself to lingual treatment.

I want my practice to be thought of as a pioneer, not a wallflower. Orthodontic products and systems never stop improving and evolving, and the best way to stifle growth and opportunity is refusing to reevaluate a new product’s potential to enrich your practice. The most costly eight words in business are: “But that’s the way I’ve always done it!”

Take lingual orthodontics as an example. When this appliance was first introduced, there may have been doubts that this type of system could create the same results for our patients as achieved with traditional, labial treatment modes.

As technology has evolved, and fully customizable lingual solutions have become a reality, we now know that—with the proper technique—it’s certainly possible to achieve the same quality of finish as with traditional, more familiar bracket systems. Awareness of aesthetic treatment options among consumers is on the rise, and it’s not unusual for patients to ask about “invisible” options. Even with the popularity of clear aligners and ceramic brackets, a lingual appliance remains the only option that’s truly almost undetectable.

So, why is now the time to consider offering lingual orthodontics in your practice? Based on my own experience finding success with this treatment modality, here are several reasons why considering it as an option in your practice can open doors.

Simply put, offering lingual systems differentiates your practice. To ensure continued success, it’s critical for your practice to take advantage of any opportunity to create a unique edge in your community.

With this said, there is a learning curve with lingual treatment (as with any new technique you may adopt). I believe it will take 20 cases to develop proficiency. New doctors must make the commitment to this technique, but if you are willing to do so, you’ll be equipped to offer a service that others in your area may not.

As orthodontists, we should be able to offer patients a variety of treatment options that fit their specific needs. If a potential customer walks into your office requesting a lingual treatment or a completely invisible solution, you don’t want to have to turn them away because you’re not properly equipped to offer the aesthetics they’re seeking.

With each lingual case I do, I consistently hear patients talking about how fast it works, and how no one can tell they’re undergoing treatment. The value here is that your practice receives a significant amount of word-of-mouth marketing—satisfied patients will tell their friends and family why they should go to your practice for treatment. I cannot tell you how many wives and husbands are both in lingual braces in my practice. In fact, I’ve done very little to market lingual treatment to my patients, and yet I still see consistent growth and more and more patients coming into our office specifically requesting lingual braces. Patients often also ask about clear aligners, offering another opportunity to talk about additional “invisible” options.

Even patients with complex cases want aesthetic treatment. We all know that not every patient is a good candidate for clear aligner therapy, but many with more complex issues still want a solution that’s discreet. Lingual systems can treat malocclusions, severely impacted or rotated teeth, anterior posterior discrepancy, and more. With 3M’s Incognito Appliance System, the system I use in my practice, brackets and archwires are customized to the patient’s anatomy, meaning less magnification and more control. Control is certainly of the utmost importance for a good finish when you’re dealing with the biomechanics of lingual orthodontics. With advancements in lingual bracket technology, there are few complexities that can’t be treated.

The mechanics of lingual brackets are not entirely different. In fact, one lingual doctor I know always says, “Treat with lingual the way you would with labial braces.” The biggest challenge is working within a shorter inter-bracket distance, which is particularly true in the lower arch. My advice regarding treatment mechanics for new lingual doctors is simple: have smaller goals at each appointment. Your goal should be to fully engage the wire into the bracket slot. If you cannot engage a particular bracket or two, at the next appointment, attempt to engage those brackets. That simple. No crazy ties. No crazy ligatures. If you are experiencing back sweat, you are trying too hard!

For orthodontists who are new to the technique, I always recommend beginning with upper lingual and lower labial treatment. In the upper arch, it is significantly easier to engage the wires and control tooth movement—and you’re working with a larger inter-bracket distance. I call this method “hybrid mechanics,” incorporating both lingual and labial mechanics. Treatment will be easier and simpler, and there is no concern with arch coordination. Many patients prefer this combination as treatment fees are often reduced.

For any new technique or treatment modality, it’s important to choose the right manufacturer and a product you feel comfortable with. For me, the choice to work with the Incognito Appliance System resulted from two key points: the bracket performs well clinically, and the company has great customer support. I cannot stress the latter point enough. The customer support for the Incognito System is truly amazing; whether I have clinical or billing questions, they are always available at a moment’s notice to provide assistance. Mastering the mechanics of lingual has been easier with a low profile bracket, and the self-retaining slot in the anterior region makes the initial appointment easier. Much of choosing a lingual system is finding a good support network, and with this product, I’ve found the education, training, and support to be top-notch.

Lingual orthodontics can be incorporated into any practice—big or small. You have an extremely busy practice and don’t think you have time to get trained in a new technique? I can relate. My practice has upwards of 2,500 new patients each year and growing, and we decided that being able to offer any treatment modality our patients request is worth putting a bit of extra time and effort into training. Our bonding appointments with lingual braces are slightly longer compared with labial braces, but our bimonthly appointment intervals are the same, 20-minute slots.

Whether or not you have a large number of patients asking for lingual treatment today, being trained in the correct technique is an incredible tool that can be used if—or, more likely, when—the opportunity arises. Putting off training and education until your practice slows down might mean you’ll never get around to it. It’s always “now-o’clock,” as I like to say.

Now is the time to consider (or reconsider) the idea of becoming trained in lingual orthodontics. With the constant evolution of products and technologies, we’re now presented with lingual solutions that provide beautiful results. Aesthetics is a trend that continues to grow, especially in light of the fact that 25% of orthodontic patients today are adults. Patients will look to you to provide the best in “invisible” solutions, and lingual appliances offer a practical solution for even the most complex of cases.

With the proper training and a commitment to mastering this new technique, you’ll have the tools to create a niche for your practice—one that will continue to pay dividends as you attract a new and diverse patient base.

Case Study

This case report will review a lingual orthodontic patient of moderate complexity, suitable for orthodontists learning the Incognito appliance lingual technique. Hybrid biomechanics of upper Incognito and lower ceramic braces, along with upper labial attachments, will be used. Wire sequencing, biomechanics, and interarch elastics will also be reviewed.

Diagnosis and Etiology

A 34-year-old female presented to our office for a lingual orthodontic consultation, with the chief concern: “I don’t like my [crossbite],” pointing to the maxillary left lateral incisor. She presented with a convex soft-tissue profile. Her nasal tip deviated left of her facial midline. Upon smiling, her maxillary dental midline was left of her facial midline.

Intraoral examination revealed an anterior and a unilateral left posterior crossbite of the maxillary left first premolar. The maxillary left molars were excessively rotated mesially out. The maxillary dental midline was 2 mm left of the mandibular dental midline (Figure 1).

Cephalometric analysis confirmed a Class II skeletal relationship (SNA: 80.7°; SNB: 74.5°; ANB: 6.2°) due to mandibular retrognathia. The mandibular incisors compensated for the skeletal relationship by protruding and proclining (L1-NB: 9.4 mm; L1-MP: 101.8°). Panoramic evaluation confirmed a missing maxillary left first premolar. All third molars were present, though only the maxillary left third molar had erupted, likely due to space resulting from the missing first premolar. Both condylar heads showed progressive osteodegeneration or “bird-beaking,” though the patient was asymptomatic.

Study model analysis revealed a Class II division 1 malocclusion canine subdivision right malocclusion. The maxillary right canine and first premolar were in almost a 50% Class II relationship. Due to the missing maxillary left first premolar, the maxillary left first molar was in a full-step Class II relationship, though the maxillary left canine was in a Class I relationship. The maxillary arch was tapered and  the maxillary central incisors deviated left of the median suture. Overjet and overbite were adequate, with moderate dental crowding.

Treatment Objectives

The patient and I identified three primary treatment objectives: 1) Correct the left side anterior and posterior crossbite; 2) Establish functional canine Class I occlusion; and 3) Coincide dental midlines and align dental midlines with the facial midline.

Treatment Alternatives

The patient was presented with two treatment options: (1) extraction of the maxillary right second premolar and both mandibular second premolars, or (2) nonextraction treatment with Class II right directional elastics and mandibular anterior reproximation.

With regard to the first treatment option, I was concerned with the extended duration of treatment, the challenge with anchorage loss of the mandibular left molars, and the hanging maxillary left third molar following space consolidation. Therefore, a treatment plan that included mandibular anterior reproximation to gain overjet, followed by Class II right directional elastics was agreed upon.

Treatment Progress

Polyvinyl siloxane impressions were taken for fabrication of the maxillary Incognito braces. The impression process is now completely digitized in my office using the iTero® digital intraoral scanner (Align Technology Inc). The second molar brackets were designed with tubes and hooks. Having tubes on the terminal bracket helps guide insertion of the maxillary lingual wires. The posts allow for placement of elastic Energy Chain (RMO Inc), which is critical to avoid space opening during Class II directional elastic wear.

I customarily order five lingual wires: 0.014-inch CuNiTi for rotational correction, two orders of 0.016 x 0.022-inch CuNiTi for leveling and aligning, 0.016 x 0.022-inch stainless steel for consolidation and anteroposterior correction, and 0.0175 x 0.0175-inch TMA for intraoral finishing and detailing. I like to order a second 0.016 x 0.022-inch CuNiTi. Often, I will step back into this wire following space consolidation in stainless steel. The CuNiTi enables posterior settling and recaptures anterior tooth position.

I will only use 0.018 x 0.025-inch stainless steel wire when I need significant overbite correction or transverse expansion. In these cases, an 0.018 x 0.025-inch CuNiTi is placed for 3 to 4 months prior to insertion of the stainless steel wire. Simply put, I do not jump from a 0.016 x 0.022-inch CuNiTi to an 0.018 x 0.025-inch stainless steel wire. The difficulty of wire engagement into the bracket slot is too great.

Figure 2. Maxillary Incognito appliances were indirect bonded.

Figure 2. Maxillary Incognito appliances were indirect bonded.

During fabrication of the lingual braces, the lower arch was bonded with 0.018-inch slot ceramic brackets (RMO Inc). Resin build-ups for bite opening were placed in the lower arch to assure the maxillary indirect bonding tray would properly fit. At the following appointment, maxillary Incognito appliances were indirect bonded using Bonding Resin A and B (Reliance Orthodontic Products Inc) (Figure 2). Both maxillary and mandibular archwires were advanced on average every 4 months, but not until the archwire fully inserted into the bracket slot. Once 0.016 x 0.022-inch stainless steel wires were placed in both arches, I delivered interarch elastics.

Figure 3. A composite button was fabricated chairside by pouring flowable into the lumen of a separator.

Figure 3. A composite button was fabricated chairside by pouring flowable into the lumen of a separator.

When wearing interarch elastics with hybrid mechanics, patients will often connect their elastics from the maxillary lingual bracket to the mandibular labial bracket for maximum aesthetics. However, some patients have difficulty hooking the elastic to the post on the maxillary lingual bracket. In these instances, clear labial buttons can be bonded. Alternatively, I will fabricate a composite button chairside by pouring flowable into the lumen of a separator (Figure 3). This technique was applied in our patient to bond aesthetic buttons on the maxillary canines.

Figure 4. Patient was instructed to wear Class II directional right elastics and triangle left elastics.

Figure 4. Patient was instructed to wear Class II directional right elastics and triangle left elastics.

The patient was instructed to wear Class II directional right elastics and triangle left elastics to swing the maxillary dental midline and correct the subdivision malocclusion (Figure 4). After the dental midlines coincided, a maxillary 0.0175 x 0.0175-inch TMA was placed for intraoral detailing. The patient was retained with maxillary and mandibular Ortho-Flextech (Reliance Orthodontic Products Inc) stainless steel thread extending canine to canine, with a nighttime overlay polyurethane retainer. Total treatment time from the start of mandibular bonding was 26 months, including 24 months in maxillary lingual braces (Figure 5).

Figure 5. Total treatment time was 26 months, including 24 months in maxillary lingual braces.

Figure 5. Total treatment time was 26 months, including 24 months in maxillary lingual braces.

In conclusion, orthodontists learning the Incognito system lingual technique should begin with cases of mild to moderate complexity. Proper case selection should include patients of good emotional health, with less than 6 mm of crowding, and less than 50% canine malocclusion. Orthodontists should strongly consider hybrid mechanics of lower labial braces, or even upper labial attachments to simplify treatment biomechanics. OP


Kravitz_NEW2013Neal D. Kravitz, DMD, MS, is a Diplomate of the American Board of Orthodontics and member of the Edward Angle Society. Kravitz has been published in numerous orthodontic journals, books, and educational materials. He lectures throughout the country and internationally on practice ethics, management, lingual orthodontics, and biomechanics. He currently maintains three thriving orthodontic practices in South Riding and Ashburn, Va, and White Plains, Md.