|Year : 2014 | Volume
| Issue : 2 | Page : 136-139
Management of bimaxillary dento alveolar protrusion with lingual appliance
Anilkumar Katta1, Navaneet Krishnan Kurunji Kumaran2, Adusumilli Sai Prakash1, Revathi Peddu1
1 Department of Orthodontics and Dentofacial Orthopedics, Sibar Institute of Dental Sciences, Takkellapadu, Guntur, Andhra Pradesh, India
2 Rajah Muthiah Dental College and Hospital, Annamalai University, Chidambaram, Tamil Nadu, India
|Date of Web Publication||20-Jun-2014|
Senior Lecturer, Sibar Institute of Dental Sciences, Takkellapadu, Guntur, Andhra Pradesh
Source of Support: None, Conflict of Interest: None
Adult orthodontics in today's contemporary world is focused mainly on esthetics. Lingual orthodontics has evolved as an adjunct while exploring esthetics. Assuring esthetics and functional balance is the current concept of invisible orthodontics. It is almost as successful as labial orthodontics and has good three-dimensional control over the dentition. As the brackets are placed near to the center of resistance of the tooth, anchorage value is higher in lingual orthodontics than labial orthodontics. With the appliance in mouth, the patient overcomes the social barriers of appearing in public and augments his own level of confidence. Proper knowledge on biomechanics ensures success with lingual appliance. The following case report presents the usage of lingual technique in closing generalized spaces by following proper biomechanics in achieving ideal occlusion and thus enhancing esthetics.
Keywords: Anchorage, biomechanics, decalcification, lingual appliance
|How to cite this article:|
Katta A, Kumaran NK, Prakash AS, Peddu R. Management of bimaxillary dento alveolar protrusion with lingual appliance. J NTR Univ Health Sci 2014;3:136-9
|How to cite this URL:|
Katta A, Kumaran NK, Prakash AS, Peddu R. Management of bimaxillary dento alveolar protrusion with lingual appliance. J NTR Univ Health Sci [serial online] 2014 [cited 2019 Dec 9];3:136-9. Available from: http://www.jdrntruhs.org/text.asp?2014/3/2/136/134891
| Introduction|| |
Most of the adult patients are reluctant to orthodontic treatment due to their unaesthetic appearance. Esthetic brackets available in the market made from tooth color plastic or ceramic did not satisfy the patient's requirements.  Another option is Invisalign, which is restricted to treat only certain kinds of simple malocclusions. From the esthetic outlook and mechanical aspect, lingual orthodontics provides the best option for comprehensive treatment of most malocclusions;  it has got good biomechanical advantages over labial orthodontics. The present article illustrates an adult patient with generalized spacing in upper and lower arches who was treated by nonextraction with lingual appliance.
| Case Report|| |
A 20-year-old female presented to the department with a chief complaint of generalized spacing. On extraoral examination [Figure 1], the profile was straight. The patient had potentially competent lips and 10 mm exposure of the upper incisors during smiling. Simple tongue-thrust habit was diagnosed on functional examination.
Intraoral examination revealed generalized upper and lower anterior spacing and proclined upper incisors, with an overbite of 2 mm and an overjet of 4 mm. Mandibular midline shifted 2 mm towards left compared to the facial midline, the lower central incisors were rotated mesial in and distal out [Figure 2].
Cephalometric analysis showed class I skeletal bases and normal mandibular plane angle (SN-MP = 32°) with mild upper and lower incisor proclination.
The patient was unenthusiastic towards labial orthodontic treatment. An alternative orthodontic treatment plan was to correct the dentoalveolar malocclusion by closing the spaces through retraction of upper and lower anterior teeth with lingual appliance. The patient was encouraged to practice positioning the tongue behind the upper lingual brackets during swallowing and speech. As a result, there was no need to use a tongue crib during or after treatment. The tongue usually assumes normal position and function at the end of treatment. 
The variation in lingual tooth morphology and difficulty in bonding on lingual surface creates the need for custom measurement for selection of appropriate bracket base thickness and torque. Indirect bonding was chosen to achieve this objective.
Upper and lower alginate impressions were made, and sent to the laboratory for indirect bonding. Lingual brackets with 0.018" slots from cuspid to cuspid and 0.022" slots for the posterior teeth were bonded using the Torque Angulation Reference Guide (TARG) apparatus.  The equipment was adjusted until the long arm of the labial face of the tooth aligned with the specific gauge curvature at the middle third of the tooth. The orientation allowed preprogramming torque and angulations before the start of the treatment.
A thorough scaling and prophylaxis was done to ensure healthy gingiva, and proper isolation was maintained before transferring the brackets to the patient's mouth. The silicone tray was transferred to the patient's mouth from the plaster model. After this, the bonding technique was similar to labial bonding. Mushroom-shaped preformed NiTi wires were used in this technique. Preformed wires were selected to the particular patient by using Forestadent mushroom-shaped arch wire chart. Stainless steel and titanium molybdenum alloy (TMA) wires were fabricated by using a turret and bird beak pliers.
Initial leveling and alignment were accomplished with 0.012 and 0.014 Nitinol arch wires [Figure 3]. Space closure was performed on a flat "0.016 × 0 .022" stainless steel arch wire, using sliding mechanics with an elastomeric chain [Figure 4].
|Figure 4: Retraction with elastic chain on "0.016 × 0.022" stainless steel wire|
Click here to view
Torque was established with "0.017 × 0.025" TMA arch wire. 0.014 stainless steel wire was used as a finishing wire. Appliances were removed after 15 months of active treatment. An upper and lower fixed lingual retainer was given for retention.
Functional occlusion was achieved with overjet and overbite within normal limits. Facial photographs show a significant improvement in the incisal exposure at rest, profile, smile, and facial appearance of the patient and lip competence was achieved with concomitant reduction in lip strain [Figure 5] and [Figure 6]. The main treatment goals were achieved with an esthetic, simple lingual orthodontic appliance in a comparatively short treatment time of 15 months.
| Discussion|| |
The prime factor considered in lingual treatment is the bracket profile, as the arch perimeter is less in lingual aspect, the bracket width should be narrower mesiodistally to serve the purpose of bonding the brackets to all teeth and to correct rotations. Posterior bite stops were placed on the molars to avoid hindrance of the brackets to the opposing teeth and to open the bite. Tongue soreness and speech difficulty were observed in the initial phase of treatment.  As the center of resistance is placed lingual to the anterior teeth, the maxillary teeth tend to tip lingually and root-labial moment is produced during space closure. Lingual technique provides superior anchorage control because of the smaller arch perimeter, which in turn increases the rigidity of lingual arch wires during retraction. ,
Vertical bowing and transverse bowing effect are the common problems encountered during space closure. Light forces avoid bowing effects and anchorage loss. Rectangular wires with curve of spee were used during space closure, to avoid vertical bowing. A buccal compensatory curve was given, extending from the mesiopalatal cusp of first molar to the distobuccal cusp of second molar to compensate for transverse bowing. These are called the compensatory curves which are used commonly in lingual cases. ,
Space closure in sliding mechanics with elastic chain may create distolingual rotation of the terminal tooth. This is a common problem during finishing, which is difficult to correct; it can be avoided simply by tying the two terminal teeth with a figure-eight ligature and then engaging the elastic chain to the mesial of the second molar.  It takes a great deal of time and effort to establish torque and ideal incisor position,  and to correct unwanted side effects in lingual treatment.
| Conclusion|| |
Much emphasis should be given to biomechanical considerations which were discussed in this article while treating patients with lingual appliance to prevent the unwanted effects and increase patient compliance. The case presented demonstrates that lingual orthodontics is an efficient tool for the treatment of adult cases with mild to moderate malocclusions, and high esthetic requirements.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]