LINGUAL SET UPS

contents
Introduction
Why indirect bonding
Lingual bracket systems

Torque Angulation Reference Guide (TARG) system

Bonding with Equal Specific Thicknessn(BEST) system

Customized Lingual Appliance Setup Service (CLASS)

system.

Slot machine

The lingual bracket jig

Transfer optimized positioning (TOP/INCOGNITO i

BRACES system)

Korean indirect bonding set up (KIS) system

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Hiro system

Convertible resin core system

Hybrid core system

Simplified technique

Orapix system

Lingual matrix system

Conclusion
References

INTRODUCTION
Aesthetics has always been a catchword among patients. With
more number of adult patients desiring orthodontic treatment,
special aesthetic demands of the patients pose a great
challenge to the orthodontic community.
To be able to serve such patients, the orthodontic community
came out with the ultimate aesthetic solution Lingual

Orthodontics.

 At present, Lingual orthodontics is a complete system in itself

and encompasses accurate diagnosis, treatment protocol,
clinical and laboratory procedures.

 In 1975, Dr. Craven Kurz of Beverly Hills, California created

his own lingual appliances by modifying labial edgewise
appliances

 Michael Diamond (J Clin Orthod, 1983) described the critical

aspects of lingual bracket placement as follows:

1.) Variation in height (y)

has a direct effect on the

labiolingual position of
the bracket (x).

2.)

Variation in tooth

thickness

at

the

same

distance from the incisal

edge

affects

bracket

placement by varying the

distance from the labial
surface.

3.)

Variation
alters

the

in

height
effective

torque in the bracket,

with either a vertical or a

horizontal insertion of
the archwire.

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4.) Brackets placed at the

same

height

(y)

on

different lingual slope

angulations
located

will
at

be

various

distances from the incisal

edge (C).
A is greater than B.

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5.) Altering the angle of the

bracket-positioning

instrument can vary the

amount of torque in the
bracket slot.

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 To achieve a bracket setup in lingual orthodontics that suits the

individual patient and the treatment objectives of the
orthodontist, proper bracket placement must be planned to
compensate for tooth form and shape; to alter the tip, in-out,
and torque; and to change the bracket position when the
planned movement does not occur.

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Why indirect bonding????

The difficulty in access and lack of easy direct visualization,
the wide anatomical variation of the lingual surfaces of the
teeth, the precision that is required in bracket placement
makes indirect bonding an essential procedure for high quality
lingual orthodontics.

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The most popular bonding systems can be divided into three

major categories:
1. Systems in which the brackets are positioned directly on the
patients pretreatment casts. Although these techniques
minimize laboratory and bonding time, they require expensive
equipment and do not use setup casts, which can be helpful
tools for diagnosis and case presentation.

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 2. Systems in which the brackets are initially positioned on a

setup cast with an ideal arch wire, then transferred to the
patients mouth using a mini tray for each tooth. These
eliminate the step of transferring the brackets back to the
initial cast, but increase the time required for bonding.

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 3. Systems in which the brackets are initially positioned on a

setup cast, then transferred to the patients initial cast for
fabrication of a transfer tray. This is a simple, effective method
that reduces chair time in bonding, but requires a precise
transfer of the brackets from the setup cast to the initial cast.

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LINGUAL BRACKET PLACEMENT

SYSTEMS
These include:
1.

Customized Lingual Appliance Setup Service (CLASS)

system.
2.

Torque Angulation Reference Guide (TARG) system

3.

Bonding with Equal Specific Thicknessn(BEST) system

4.

Slot machine

5.

The lingual bracket jig

6.

Transfer

optimized

positioning

(TOP/INCOGNITO

BRACES system)
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7.

Korean indirect bonding set up (KIS) system

8.

Hiro system

9.

Convertible resin core system

10. Hybrid core system

11.

Simplified technique

12.

Orapix system

13. Lingual matrix system

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The Customized Lingual Appliance Setup

Service (CLASS) system
Described by Scott Huge, this technique involves an integrated
method of lingual bracket placement and indirect bonding.
Method:

- An ideal setup is made from the original malocclusion cast and

brackets are placed on this setup.
- This ideal set-up or template is then used as a physical guide to
place the lingual brackets in an ideal configuration.
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CLASS METHOD

Brackets transferred from setup model to malocclusion model

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 Advantage

It takes into account the anatomical discrepancies in the

lingual surfaces of the teeth.

Disadvantages
Demands maximum accuracy from the original models &
instructions provided by the clinician.

Tremendous attention to detail must be exercised at all steps to

avoid inaccuracies in bracket placement.
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Torque angulation reference guide (TARG)

This technique of bracket placement was developed by Ormco
in 1984.

It permits bonding of brackets in the laboratory, at an accurate

distance from the occlusal edge of each tooth with respect to a
horizontal reference plane.
A labial reference gauge is used to orient individual teeth.
Using only one unique angulation model, the TARG allows

pre-programming of tip and torque before the start of

treatment.
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Torque Angulation
Reference Guide.
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 Advantages:
- It is an accurate and quantified two-dimensional system.

- Allows accurate placement of the brackets on the cast without

need to cut out the teeth and place in wax.
Disadvantages:
- The system does not take into account the labio-lingual
thickness of teeth.

- The distance of the bracket base and the labial surface varies
according to the level of bonding & tooth type.
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Fillions Lingual Indirect Bonding

System
This system was developed by Dr. Didier Fillion of France in

1987.
Also known as Bonding with Equalized Specific Thickness
(BEST).
It was designed to consider the labio-lingual thickness of the
individual teeth during bracket placement.

A caliper is added as the thickness measurement system.

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 Permits us to avoid all first-order

bends, except the ones between the
cuspids and bicuspids and between

the bicuspids and molars. This

considerably

reduces

chairtime

during archwire bending.

Everything is measured and

registered: height, angulation(tip),

torque, and thickness.
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Transfer system

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DALI program
(DALI= Dessin Arc Linguale Informatise)
1. It permits us to obtain an extremely
accurate tracing of the finishing arch
wire, at a 1:1 ratio.

2. It allows us to know with a very high

accuracy (with 0.1 mm) the width of
the first-order bends placed between

the

cuspids

and

bicuspids,

and

between the bicuspids and molars.

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Individualized archwire template produced by the DALI program

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 3. During treatment, it allows us to know the ideal arch shape

needed to achieve a good occlusion, especially in asymmetric
cases.
4. It permits us to preform all archwires with great precision,
except for the first ones which are bent from the copy of the

bonded brackets on the initial model.

5. It is not necessary to coordinate the archwires during
treatment because the drawing of the upper and lower
archwires are made from the same labial arch curves.
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 Advantages:
Easy and accurate
Reduces chairtime, increases clinical efficiency
Standardisation of the thickness decreases first order bends
except between cuspidbicuspid and bicuspid molar.

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The Slot Machine

Introduced

by

Dr.

T.D.Creekmore in 1986, the

Slot Machine was meant to be

used with the Conceal bracket
system.
It also used a labial reference
to position the brackets like

the TARG machine.

Laura Buso-Frost;Dider Fillion : An overall view of the different laboratory procedures used in conjunction with
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lingual orthodontics : seminars in orthodontics :vol 12 ,no3,2006,203-210

 The procedure consists of positioning each tooth to a

prescribed torque and angulation; the machine orientates the

bracket slot with the Andrews labial archwire plane (LAplane).

The slot machine can be used for the placement of brackets
having either horizontal or vertical access archwire slots.

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Advantage

No model tooth set-up is required

Disadvantage
Difficulty in managing the many pieces of the slot machine

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Lingual Bracket Jig

Dr. Silvia Geron in 1999 introduced lingual bracket jig which

is a chairside direct bonding system.

It is used with a horizontal slot bracket.
The basic idea behind the lingual bracket jig (LBJ) is that
lingual tooth anatomy and inter-tooth relationships are
amenable to a lingual preadjusted edgewise approach.

Geron S: The lingual bracket jig. J Clin Orthod 33:457-463, 1999

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The jig transfers the Andrews Straight-Wire Appliance labial

bracket prescription to the lingual surface. Thus, the bracket
slots line up around the arch, parallel to one another and to the
occlusal plane, while the prescription provides tip, torque,
rotation, and in-out.

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The LBJ consists of:

A set of six jigs, one for each

of the six maxillary anterior

teeth,
An accessory universal LBJ for
the maxillary posterior teeth
(no

torque

or

angulation

prescribed).

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LBJ transfers labial bracket prescriptions to lingual brackets

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 The tip of the labial arm incorporates a prescription, similar to

that of a preadjusted labial bracket.
The lingual arm, which holds the lingual bracket, slides into
the labial arm.

When the lingual bracket is mounted on the LBJ, the lingual

bracket slot is parallel to the labial slot. When the labial arm is
positioned correctly, the lingual bracket is automatically
placed in its correct position.
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A.

Labial

arm

of

LBJ

positioned on labial surface

of

tooth,

duplicating

location of labial bracket

relative to LA point.

B.

Lingual
automatically

bracket
placed

in

correct position.

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 Advantages:

- Lingual bracket positioning with the LBJ is simple and quick,

and requires no special training.
- The LBJ automatically incorporates the Straight-Wire labial
prescription into the bonded lingual brackets in all dimensions.
- This allows the orthodontist to perform direct as well as indirect

bonding as in-office procedures.

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 Disadvantages
limited number of prescription jigs available

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Transfer Optimized Positioning

(TOP/INCOGNITO i BRACES system)
Developed by Dirk Wiechmann
The TOP system uses a set-up technique similar to that used for
the BEST system, allowing the brackets to be placed directly
on the malocclusion model.

The technique uses the TARG Professional, which has a

bracket holder for twin brackets and tubes, modified reference
arm in addition to the horizontal and vertical measuring
systems first described by Fillion.
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Dirk Wiechmann : Lingual orthodontics (part -1) :Laboratory procedure ; J orofac orthop ;1990;60:371-9

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 The target set-up is used to find the optimal height for the
brackets.
Once the height is determined the brackets are positioned
directly on the malocclusion model, as closely as possible to

the lingual surface of the teeth without in-out compensation for

labiolingual thickness differences.

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 Unlike other techniques, there are no thick resin bases for

compensation of thickness differences; these differences need

to be compensated for by archwire bending.
The

archwires

sequence

for

each

case

is

produced

automatically by a computer-controlled bending robot .

Most of the work is delegated to laboratory staff, thus

reducing chairside time.

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 The fit to the palatal surface of each tooth is extremely accurate

and the prescription for each bracket should be fully expressed
for each tooth, provided the correct arch wires are used and they
are fully engaged into the bracket slot.

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Korean Indirect Bonding Set-up (KIS)

System
The KIS system was developed by members of the Korean

Society of Lingual Orthodontics (KSLO) and uses a bracketpositioning machine that allows the positioning of all brackets
at once .

Once again it is necessary to create a set-up model; however,

the set-up is created with the help of a special set-up model

gauge for increased precision.

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 Advantages
It is a very precise system that places the bracket accurately
and eliminates the need for any bracket repositioning during
treatment.

It allows for bracket height differences between anterior and

posterior teeth, which facilitates the intrusion of anterior teeth.
Overall, its accuracy assists the clinician in attaining a high
standard of treatment.
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Hiro system
(Modified CLASS technique)
Introduced by Hiro and later improved by Takemoto and
Scuzzo.
Method:
- An ideal archwire is made on the setup using a full size
rectangular archwire.
- The lingual brackets are transferred onto this wire and secured

with elastic ligatures.

- Single rigid transfer trays are fabricated for each tooth.
Scuzzo G, Takemoto K: Hiro System Laboratory Procedure, in Scuzzo G, Takemoto K (eds): Invisible orthodontics:
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current concepts and solutions in lingual orthodontics. Germany, Quintessense 39-44, 2003

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 Advantages:

- There is no need to transfer brackets from the setup model to the

original malocclusion model.
- Accuracy is improved due to individual transfer trays.
- Bonding of one tooth is not affected by position of other teeth.
- Rebonding is easier.

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Convertible resin core system

The most significant challenges involved in indirect bonding

for lingual orthodontics have been:

o Keeping the brackets stable enough for precise positioning

o Making it easy to remove the indirect transfer tray.

o Bonding in areas with difficult access.

o Using the same materials for accurate rebonding when
necessary.

75 J Clin
Kim T, Bae G, Cho J: New indirect bonding method in lingual orthodontics: convertible resin core system.
Orthod 34:348-350, 2000

 This system uses hard resin to prepare the individual transfer

trays and an elastomeric ligature to hold the tray and bracket
together.

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 Advantages
This allows accurate repositioning of the bracket within the

resin core and the trays can be reused in cases of bracket

failure.

Disadvantages
The use of unitary trays makes the initial bonding session

longer and the technique still relies on a set-up model to

position the brackets.
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Hybrid core system

The Hybrid Core system developed by Matsuno combines the

favorable properties of silicone and composite resin in the

construction of its indirect transfer tray.
Silicone covers the bracket and this in turn is covered by
composite resin.
This combination allows for stable positioning of the transfer

tray within the mouth, followed by easy removal of the

silicone component from the bonded bracket.
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Matsuno I, Okuda S, Nodera Y: The hybrid core system for indirect bonding. J Clin Orthod 37:160-161,2003

A groove guided indirect transfer system

for lingual brackets
Prieto et al in 2005 described this procedure using a red
duralay resin for the bracket transfer.
The key improvement is a change in the position of the red

DuraLay resin: Instead of being placed at the center of the

bracket pad, the resin is applied more incisally or cervically,
depending on the tooth, thus freeing the bracket from potential

interference.

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Prieto, Ishikawa & prieto;A groove guided transfer system for lingual brackets; J Clin Orthod 2007 ;34;372-376

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The Ray Set system

This system utilizes a 3-dimensional goniometer for analysis
of the first-, second-, and third-order values of each individual
tooth.

Both pre- and post-setup values of individual teeth are

evaluated and the amount of orthodontic tooth movement for
each tooth on the setup model is calculated.

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The RAY SET device (a) with a 3D goniometer(b)

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The Mushroom Bracket Positioner

Developed by Kyung et al, in 2002, the mushroom bracket
positioner is a machine for accurate bracket placement on an
ideal setup.

At present, 5th generation of MBP is available which places

brackets to accept a straight wire.

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Simplified technique
Simplified Technique The Simplified Technique is associated
with the development of the new STb brackets. The brackets
are positioned directly on the malocclusion model by using a
bracket placement plier or simple tweezers.

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ORAPIX SYSTEM
Orapix System The newest lingual orthodontic laboratory

technique is the Orapix system.

This system developed in South Korea by the company of the same
name ,it is distributed in Europe by Eurapix.
Orapix is at first a system of digitalization which transforms the
information of a pair of impression or a pair of plaster models into
3D digital data.

Didier Fillion : Lingual straightwire treatment with the orpix system: J Clin Orthod 2011: 11 :448-497 97

 A scanner will scan a patients model and create a three

dimensional (3D) data file. The orthodontist will receive the 3D

data file of the patient and a 3-Txer software package via the
Internet.
With the 3-Txer software the orthodontist will visualize a 3D
model and will be able to create his own virtual set-up on his

computer for that particular patient.

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Clinical advantages of the Orapix-straight wire lingual technique :International Orthodontics 2010 ; 8 : 125-151

 Orapix, it is also a system of bracket placement on fully

individualized virtual set-up and manufacturing of Jigs of

transfer

by

the

technology

CAD

CAM.

The Orapix straight-wire system , worked out by Dr Didier

Fillion, facilitates considerably the lingual technique because
it allows the use of straight wires without bend.

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Advantages
Eliminates the phase of laboratory & manual errors
Individualise the location of every bracket
Use straight wires without bends
Teeth move gradually during the treatment towards the ideal
occlusion given by the set up
Decrease the number & duration of the appointments.

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Lingual matrix system

LINGUALMATRIX is the first and only system in the world
that involves fully digital process developed by Praveen shetty
& Manjul jain.
Treatment plan starts with 3D scanning of u/I models using 5

axis optical white light scanner.

Thereafter, LINGUALMATRIX moves each tooth to its ideal
position either virtually / manually.

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 LINGUALMATRIX software produces a cad model of

lingual bracket with a customized base. Which undergoes a
very precise manufacturing process using avant-grade laser
sintering machine to manufacture a customized single piece
3D lingual bracket that adapts seamlessly to the shape and
contour of the teeth.

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 The automation & digitization of the entire system assures the

perfect finish and smile, with minimum physical and mental

fatigue.
This system develops a single piece customized bracket which
fits perfectly on to the teeth, facilitating direct bonding and re
bonding of detached brackets.

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 Advantages
Lingual matrix offers one of the most Economical cad cam
based customized bracket in the world.

A single piece 3D lingual bracket system

A State of the art manufacturing process from virtual setup to

laser sintered 3D brackets.

Choice of using straight arch to mushroom shaped archwire
as per the demand.
Horizontal slot opening for better bio-mechanical control.
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 Add or delete hooks on Brackets as per requirement.

LINGUALMATRIX can reprint bracket at any point of time
with prescription.
Ease of rebonding due to single piece metal bracket.

LASER etched marketing system for easy identification.

Versatility of using different form, features and sizes of
brackets as per the occlusion and requirement of the case.

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Conclusion
As bracket placement is considered to be an important step in
lingual orthodontics it has to be done with extreme precision
Each bracket placement system has its own advantages &

disadvatages so the clinician must select the suitable system

based on the need, equipment available and the cost factor

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References
Laura Buso-Frost;Dider Fillion : An overall view of the
different laboratory procedures used in conjunction with
lingual orthodontics : seminars in orthodontics :vol 12
,no3,2006,203-210
Romano : Lingual orthodontics
Geron S: The lingual bracket jig. J Clin Orthod 33:457-463,
1999
Wiechman D: Lingual Orthodontics (part 1): laboratory
procedure. J Orofac Orthop 60:371-379, 1999
109

Weichmann D: Lingual Orthodontics (part 2): arch wire

fabrication. J Orofac Orthop 60:416-426, 1999

Geron S, Romano R: Bracket positioning in lingual

orthodonticscritical review of different techniques. Korean J

Clin Orthod 2:39-44, 2003
Scuzzo G, Takemoto K: Hiro System Laboratory Procedure, in
Scuzzo G, Takemoto K (eds): Invisible orthodontics: current
concepts and solutions in lingual orthodontics. Germany,

Quintessense 39-44, 2003

Prieto, Ishikawa & prieto;A groove guided transfer system for
lingual brackets; J Clin Orthod 2007 ;34;372-376

110

Kim T, Bae G, Cho J: New indirect bonding method in

lingual orthodontics: convertible resin core system. J Clin
Orthod 34:348-350, 2000

Matsuno I, Okuda S, Nodera Y: The hybrid core system for

indirect bonding. J Clin Orthod 37:160-161,2003

Clinical advantages of the Orapix-straight wire lingual

technique :International Orthodontics 2010 ; 8 : 125-151
Didier Fillion : Lingual straightwire treatment with the orapix
system: J Clin Orthod 2011: 11 :448-497
111