LIN G UAL ORTHODONTICS VERSUS LABIAL ORTHODONTI CS:

A N OVERVIEW

A utho r 's n am e
Dr. D in es h K. 8agga
Professor & Head
Deptt. of Orthodontics & Dentofacial Orthodpaedics,
I.T.5. Ce ntre for Denta l Studies & Resea rc h, Murad f'\.iagar, Ghaziabad (UP)

Abstract lingual orthodontics came into existence to e liminate the visibility of the appliance by sparing the labial surfaces
and making use of lingual surfaces to fix orthodontic attachments for esthetic reasons on the demands of adu lts.
This lingual technique presented a challe nge being much different in treatment approach as compared to labial
orthodontics due to working area with poor accessibility, anatomical variations of lingual surfaces posing difficulty
in getting accuracy of bracket positioning, djfferent mechanica l considerations due to the position of orthodontic
attachments having different relationship with centre of resista nce, different nature of problems to the patients
due to its different location and various other factors. It requires a lot of patience, efforts, skill and time from the
orthodontist and good cooperation from the patients understa nding the extended chair time, increased cost,
increased duration as well as the discomfort associated with it especially speech and tongue soreness. This article
is an attemptto present an overview of lingual orthodontics as compared to labial orthodontics.

Abbreviated Title LINGUAL ORTHODONTICS

Keywords Ungual Orthodontics, Labial Orthodontics.

I NTRODUCTI ON labi al/b u cca l surfa ce but different trealm e nl

Fixed orthodont ic appliance has been brought into co nsid erations are required in lingual orthod ontics than
practi ce by making attac hm ents fixed o n th e labial o rthodonti cs.
labial/bu cca l surface. Teeth have only lab ial/bucca l Co n s ide ra ti o n s RegardingAp p lia nce placement
surfaces and lingual surfaces available for fixing the
Lingual o rthod o ntics presents diffic ulty for appliance
alLachments of th e appliance to facilitate the delivery of
placement firstly, du e to difficu lty in direct accessibi lity
th e desired force. Labial/b ucca l surfaces allow more
to lingual surfaces and secondl y, due to anatomic
co nvenient approach for m anipul ati o n of fixed
variati o n s of the lingu al surfaces and thereby, increasi ng
appliance. The need of fixing th e attachme n ts on th e
the chances of inaccuracy of brac ket positio ning.
lingual surfaces better known as lingual orth od o ntics has
Precise bracket pOSitioning is important for successful
evo lved in an attempt to hide th e appliance due to
treatment. A change in bracket position on lingual sid e
estheti c reasons. The demand especially ca me from the
wi ll have a greater effect on th e final tooth position than
adu lts due to psych osoc ial reason s. Lingua l orthodontics
the same change when app lied o n labial aspect beca use
came into ex iste nce as a viable option for orthodontic
lingu al brackets are b o nd ed distally from the labial
pati ents in 1970's with the pioneering works of C rave n 1
surface that has to be aliened. Precise bracket
Kurz of USA and Kinya Fujita of Japan.' Three-
positioning is achieved either by direct bonding with
dimensional control of crown and root position is
lingu al jies. l which also enab les indirec t bondingor by
possible with attach m e n ts o n th e lingual surface as

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indirect bo nding using TARG syste m (To rqu e Angulation
Reference G uide),4 th e slo t m ac hin e, ~ the CLASS system
(C usto mized Lingual Appl ia nce Setup Service)," th e
CRCS syste m (Co nvertibl e Resin Core Syste m )/ the
bending arch technique, ft'l the TOP syste m <Transfe r
Optimized Pos itioning). rolf Direct b o nding is less
accu rate, th erefore indirect bonding is preferred. The
practi ce of lingual o rtho dontics requires th e support of a
labo rato ry. A few diffe rent set of instrum en ts are added
to t he armamentarium to fac ilitate working o n th e
lingual aspect of th e d ental arc h .
Co ns iderat io n s Regard in g Mec h a nics
Wire bending is more co mpl ica ted as it requires th e
sizea bl e first order be nd o n the lingual side betwee n
cani ne and the premo lar making the archwire in a
mushroo m shape. This problem is overcom e to some
extent b y th e use of prefabric ated archwires wi th a
straight w ire conce pt. Tho ugh th e usual approach of
pl ac ement of orthodontic attachments is th e use of
cu stom brackets with elaborate prescription all owing
th e u se of preformed archwires w ith littl e or no wire
bending but, recently the o ption of using less ex pen sive
brackets with little o r no straight w ire co mpen sa tion s
with arc h wires having all the be nd s incorporated by a
wire bending robot using laser sca ns is being ex plored .
The robot arch wire fabrica ti o n is too ex pe nsive at
present. 11
Th e int erbra cket span is redu ced espec ially in the
anterior regio n co n Side rably, m aking th e wi re see m
approximate ly thre e times as stiff as wh en u sed with
lab ia l fixed appliance fo r first order, seco nd o rde r bends
and approximately one and a half times as stiff fo r third
u
o rd er be nd s. Point of fo rce applica tion is differe nt in
linaual orthodontics influ enc ing the relationship of lin e
of fo rce with centre of resistance. Therefo re, tooth
m ove m e nts with lingua l orthodontics need a different
biomechanical con sid e ration than that w ith labial
orthodontics. Redu ced di stan ce between point of force
appli ca ti on and centre of resistance in th e lingua l
technique leads to sm all er m o m e nts of fo rce m akin g
to rque contro l more difficult as well as influ enCi ng first,
sec ond and third ord er bends. r~ Verical forces in lingual
o rthodo nti cs may produce muc h m ore complicated and
unpredictable tooth movement beca use these ve rti ca l
forc es affect th e teeth differe ntl y with change in too th
incl ination and al so muc h more sen siti ve to the bracket
p osition than that in labial orthodonti cs. I ~ In labia l
orthodonti cs, intrusion is accompanied bv labi al tipping
du e to fo rce vector pa ss ing labial to ce ntre of res istance.
In lingual orthodontics, intru sio n o f normally inclin ed o r
procl ined teeth is accompanied b y little or no labial
tipping du e to forc e vector pa ssing through or closer to
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ce ntre of resistance whereas that of retroclined teeth is
accompanied b y further lingual tipping du e to fo rce
vecto r passing lingual to th e centre of resistan ce. In labial
orthodontics, ex tru sion is accompani ed by labial root
m ove m e nt, but in lingual orthodon ti cs, extru sio n shows
compl ex ity in th at teeth with differe nt inclinati o ns
except those with m o re than 20% inclinati o ns to th e
occlusal p la ne sho w lingual root move m ent latter
showing labi al roo t movem ent. "
Redu ced arch pe rimeter in the anteri o r reg io n o f lingual
tooth aspect makes it diffi cult to apply light forces and
also reduces acti va ti o n ra nge as well as con stan cy of
force. I nc reas ing th e wire le ngth by in corporatingly
loops is not possible beca use of limited space. H ence,
the o ption s for increasing th e res ili e ncy of th e wire are
ei th er by th e use of resi lie nt wires with d ecreased
m o dulu s of e lasti c ity suc h as shape m e m ory wires or
decreased cross section of the wire. r ~
The smaller arch pe rim ete r, b y in creasing the rigidity of
lin gual arch wi res, increa ses the anchorage control
during retra cti o n .'" Th e highe r anc h o rage va lu e of
poste rior teeth wi th the lingual appl ian ces is firstl y, du e
to th e n ea rn ess o f the lingual brackets to the ce ntre of
resistance of the teeth reduc ing the c hances of tipping
and secondly, by c rea tin g a bucc al root torque and
di sto ling ual rota ti o n of the rnolar crown during following
spa ce closure, in turn providing co rti ca l bon e
anchorage r~
Retrac ti o n fo rce u sed with lingual techn iq ue is threefold
lower than that with the lab ial techniqu e b ecau se o f the
u se o f sliding m echan ics wi th ela sto m e ric c hain showing
m o re than 50% fo rce decay in four weeks. """ In lingual
orthodon tics retra c ti on fo rce wi th intrusive force in an
equal arnount app lied to norma lly incl ined or proclined
tee th sh ow s a net force vector pa ssing lingual to ce n tre of
resistan ce leading to lingual tipping of m aX illary anteri o r
teeth in contrast to th e labial tec hniqu e where the net
force vector passes through the centre of resistance.
Hence, in lingual orthodontics thi s lingual tippin g
co upl ed with ante rior bite plan e e ffect of lingual
brac kets o n m ax illary anterior teeth ca using posterior
discl usi on lead to loss of lateral occl u sa l function
resulting in vertic al bowing effect. The refore, retraction
is c arried out using stiff wires alongwith less force with
more intrusi o n and to rquing fo rce in lingual
orthodon tics. The sliding mechani cs wi th lingual
o rth odontics also has th e ad va ntage of be ing effecti ve in
preve nti ng tran sve rse bowing effec t lead ing to
undesired bucca l tipping of premolars a nd di stolingual
rotation of m o lar without using any auxiliary such as
tran spalatal arch . The lingual orth odontics shows
ex pansive nature especiall y du ring alignme nt. Thi s
effect was first attributed to increase in to ngu e pressure
as a resu lt of p lacem ent of app lianc e on th e lingual
as pect but later it was rea l ized to be a m echani ca l sid e
effect/bowing effect, which ca n be contro ll ed b y u se of
stiff w ires w hile retra ctio n I
Con s ide ratio n s Regarding Pa ti e nt's Accepta bility
to the Applia n ce
Bo th labial and lingual patients fee l so m e di scomfort at
th e beginningof th e treatment and ad aptatio n pe rio d for
the patient to be comfo rtab le with the app li ance was th e
sim il ar in t.he patie n ts with e ithe r of th e technique i. e. 4
weeks. ltm Pati en ts fe lt d isco mfort loca lized in lip and
cheek areas w ith labial app li ance, w he reas those with
lingual appliance complai ned of tongu e so re ness as a
c o mmo n occurre nce. l<r:.mn s No differe nce was observed
in the ea ling and o ral h ygie ne maintenance, but food
sti cki ng was reported hi gher in lingual group .lO Speech
was found to be severe ly affected in patients w ith lingual
Hrlf
appliance. • Patie nt sho u ld be very cooperative and
able to und erstand the di sco mfo rt ca used b y the
app liance and need to be to leran t.
Lingua l o rthodo nti cs is associated with ex tended
chairtime in co mpari son to labia l o rth od o nti cs b y 3 0 %
to SO% o r even upto 1 00% according to diffe rent
lH1
sl udies. Increase in time, effo rt and suppo rt of a
labo ratory all lea d to increase in th e c ost, whic h ma y
d iscourage a pati ent fro m see king lingual o rthodonti c
treatment.
In labial o rtho d o nti cs, wh ite spots o n the labial surfaces
around th e o rtho d o ntic attac hm en ts m ay be di scovered
after the removal of appl ian ce leading to unestheli c
appeara nce. In lingual o rth od o ntics, such chances of
w hit e spOI fo rmati o n o n labial surfaces c an be
el im inated b y m ainte nance o f prope r o ral h ygiene as
labia l surface is spared of o rthodo ntic attac hm en ts. Thi s
advantage is i n favour of lingual o rtho d o nti cs.
Cons id eratio n s Regarding Select ion o f Applia n ce
The lingual appliance has a b ite o pe ning effect du e to
the positio n of lingual bra ckets o n m ax illary anterior
teeth contacting inc isa l surfaces of lowe r inci sors in d ee p
bi l e cases as well as expa n sive natu re. The refore, the
favourable cases are low angle, d eep bite cases, mild
crowding cases requiring ex pansion and class II cases
requiring max illary pre m o lars extrac tion . Difficult c ases
are th ose requiring all first premolars extraction, hi gh
angle cases, anteri or open bite c ases and surgical cases.
U n favou rabl e cases m aking co ntraindicati o n to lingu al
orth od o nti cs are cases having short clinica l crowns less
than 6 mm, poor pe riodo ntal status, poor o ral hygiene.
patien ts having c riti cizing and restless tend ency with a
l itt le ho pe o f understa nding th e probl ems of di sco mfo rt,
72
high a ngl e cases, severe class II discre pancy and acute
, 1ft
TMJ dysfun ction. ·
Conclu s io n
Lingua l appl ian ce is a viabl e o ptio n fo r the patients
see king fixed orthodontic treatment. It is a we ll -
tolerated appliance. Speech probl em and tongue
sore ness m ay require so m e m o re time for adaptati on to
t he app li a nce. Lingua l tec h niqu e du e to poo r
accessi bility, variations in anatomy of lingual surfaces,
need o f a laboratory and compli cated m echanics,
increased du ratio n and cost , need s a mu ch diffe renl
consid erati o n as compa red to labial o rth odontics.
H e n ce, a good co mmuni ca ti o n betw ee n the
o rtho d o ntist and the patie nt is required so that patient is
ab le to unde rstand the problem s associated with lingual
o rthodo ntics and ad o pts a positive attitud e to accept th e
appliance with good coo pe ration.
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Address for correspondence
Dr. D in esh K. Bagga
Professor & H ead
D eptt. o f O rtho d o nti cs & D ento facial Ortho dpaedics,
I. T.S. Centre fo r D e n ta l Studies & Resea rc h,
Murad N aga r, Gh az ia bad (UP)
Phone No : 0 986807 1 583, 01 2 0 - 326 3 0 3 0
73
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