Lingual Orthodontics

Didier Fillion
Moscow
April 16-17 2006

Didier FILLION

has practiced lingual orthodontics exclusively in Paris since 1987.

and in London since 1997.
He belongs to the French Orthodontic Society, the American
Association of Orthodontists and the American Lingual
Orthodontic Association. He is founder member and Honorary
President of the French Lingual Orthodontic Society, founder
member and Honorary Secretary of the European Society of
lingual Orthodontics, Founder member and President of the British
Lingual Orthodontic Society. He is founder member and President
of the World Society of Lingual Orthodontics .
He is president and co-organizer of the first International Lingual
Orthodontic Congress held in Paris (1991), scientific president of

the second meeting of the European Society of Lingual

Orthodontics (Monaco 1996), and vice-president of the first
International Congress of Lingual Orthodontics (Tokyo 1999) . He
is course director of the two - year program in lingual Orthodontics
at Ren Descartes Paris-V University
He has held courses in lingual orthodontics around the world
(USA, Japan, Sweden, Spain, Portugal, Denmark, Germany, Italy,
Korea, England, Brazil, Chili, Russia, Thailand, England, Emirates,
Saudi arabia, ) and periodically conducts hands-on in-office
courses in English. He regularly has foreign colleagues come to in
his office to train in order to increase their knowledge and clinical
experience. He invests a lot of his time and energy in order to
improve the technique and design new materials.
Dr Fillion is not only considered to be a leading lingual orthodontic
expert but, today, he is the only orthodontist in the world to
maintain a full - time lingual orthodontic practice in Paris and
London.

Please, feel free to contact me:

E-mail: smile@drfillion.com

Introduction

The recent increase in the popularity of lingual orthodontics in

adult patients is due to the appliances not being visible during
treatment. This allows a large number of patients to be treated
who would otherwise refuse to wear more visible labial braces.
The advantage of lingual appliances over other aesthetic
appliances, such as Invisalign, is that it can treat all kinds of
malocclusions irrespective of the severity of the malocclusion. It
may also be used successfully in the management of complex
restorative cases where orthodontic treatment merely acts as a
step in providing alignment, correct angulation and correct spacing
for the successful placement of bridges and implants.
However, following the placement of lingual appliances there is an
adaptation period for the patient to overcome the initial discomfort.
The main problems experienced are soreness of the tongue and
disturbance in speech. These factors may cause an initial
reluctance to accept wearing lingual braces (1, 2, 3).
A new generation of lingual bracket, STb, appears to overcome
these initial difficulties, increasing patient comfort and producing

results to a high clinical standard.

Description of the Appliance

STb brackets take their name from Dr. Scuzzo and Dr. Takemoto,
who have spent many years developing their new bracket based
upon personal clinical experience.
The most significant change in design is the size of the bracket.
The new STb lingual brackets are smaller and more closely
adapted to the lingual vestibule. The dimensions of the incisor and
canine brackets are 2.5mm (width) by 1.5 mm (thickness). The
premolar and molar brackets have a thickness of only 1.5mm (Fig
1a&b).

Figure 1a & 1b: STb brackets for the maxillary incisors and canines with an

antero-posterior thickness of 1.5mm

The shape of the bracket has also been dramatically changed.

There are three small wings (two occlusal and one gingival) and a
0.018 x 0.025 slot for the arch wire. The absence of a hook and
bite plane further reduce the overall dimensions of the bracket
leading to greater patient comfort.

Fig 2a: A frontal view of the to compare the differences in the

dimensions of the new STb and Ormco-Kurz 7th generation bracket

Figure 2b: A visual comparison of the differences in the dimensions of the

STb
bracket (left side) and the 7th generation Ormco-Kurz (right side) bracket
for themaxillary arch

Comfort

The reduced dimensions and more round edges of the new STb
bracket spectacularly reduce patient discomfort when the brackets
are first placed.
A previous study investigating patient comfort following placement
of the 7th generation Ormco-Kurz bracket emphasised that there
is a significant adaptation period for patients.
After three months of treatment, when asked about the discomfort
caused by the appliance, 36% of patients responded that the
period of adaptation was initially greater than 3 weeks.
Disturbance of speech was still an issue for 18% of patients and
difficulty in eating for 12% of the patients (4).

On repeating this study in patients who had STb brackets placed

only one month previously the results were considerably different
(Table 1a- 1f). There appears to be a shorter time for patient
adaptation when asked about comfort. The irritation to the tongue
is very clearly diminished. The ability of the patients to endure the
discomfort also appears to be improved with the new smaller
brackets suggesting they are more comfortable.
Speech
Speech disturbance is no longer an issue at the end of the first
month of treatment. A video demonstration, at the 6th Congress of
the European Society of Lingual Orthodontics, showed that there
was no perceptible impairment of speech immediately after
placement of the new STb brackets. The patients appeared quite
comfortable and confident in repeating the phrase She sells sea
shells on the sea shore.
The overall patient perception of greater comfort of the new
brackets suggests that patients with lingual brackets concentrate,
unsurprisingly, on the fact that there is an
increased difficulty in eating when the appliances are placed. This
problem is not confined to patients with lingual appliances only, as
this is a common complaint ofpatients with labial appliances at the
end of the first month of treatment.
Another encouraging outcome of this survey is that patients are
less disturbed in their social and professional working lives with
the new brackets after just one month.

Table 1a: Patient adaptation to STb brackets (after 1 month) compared to

the 7th generation Ormco-Kurz (after 3 months).
Duration of adaptation
Less than 1 week
2 weeks

Ormco Kurz
months)
9%
29%

3 weeks
Greater than 3 weeks

26%
36%

(after

3 STb ( after 1 month)

45%
36%
19%
0

Table 1b: Patient perception of the adaptation period to STb brackets (after
1 month) compared to the 7th generation Ormco-Kurz (after 3 months).
How did you find this
adaptation phase?
Easily Bearable
ModeratleyBearable
Difficult

Ormco Kurz
months)
27%
45%
27%

(after

3 STb ( after 1 month)

36%
64%
0%

Table 1c: Factors patients found difficult after bracket placement. A

comparison of STb brackets (after 1 month) compared to the 7th generation
Ormco-Kurz (after 3 months).
What was the most
uncomfortable aspect?
Irritation to the tongue
Difficulty in speech
Difficulty in chewing

Ormco Kurz
months)
44%
36%
20%

(after

3 STb ( after 1 month)

25%
0%
75%

Table 1d: Disturbance in the work place caused by STb brackets (after 1
month) compared to the 7th generation Ormco-Kurz (after 3 months).

Do
the
appliances Ormco Kurz
disturbyour
months)
professional activity?
2 weeks
12%

(after

3 STb ( after 1 month)

0%

Table 1e: Disturbance in social activity caused by STb brackets (after 1

month) compared to the 7th generation Ormco-Kurz (after 3 months).

Do
the
appliances Ormco Kurz
interfere
months)
with
your
social
activity?
Less than 1 week
6%

(after

3 STb ( after 1 month)

0%

Table 1f: Disturbance in speech caused by STb brackets (after 1 month)

compared to the 7th generation Ormco-Kurz (after 3 months).

Are you able to speak

normally?

Ormco Kurz
months)
18%

(after

3 STb ( after 1 month)

0%

Maintenance of Oral Hygiene

Difficulty in maintaining a high standard of oral hygiene has been
widely experienced by patients wearing fixed lingual appliances.

Generally all patients are encouraged to see a hygienist every

three months during treatment, if possible with arch wires
removed.
The STb brackets appear to have greatly facilitated maintenance
of a high standard of oral hygiene. Clinically less gingival
inflammation has been noted around the bracket base. This may
be due to three factors in the design of the bracket:
1. The small size of the brackets mean that there is an increased
inter bracket space which may be more easily cleansed (Fig 3 & 4)
2. The brackets protrude a smaller distance from the tooth and
appear to trap less food.
The absence of a hook may contribute to this observation.
3. The smaller size of the bracket base means that they may be
positioned away from the gingival margins making it easier to
clean this area and reduce the amount of gingival inflammation
from plaque accumulation.

Fig 3: A comparison of the lateral profile of the STb and Ormco-Kurz incisor

bracket.
Note that the STb bracket is bonded slightly more incisally so that it lies away
from the gingival margin. The absence of a hook prevents a natural food trap and
facilitates brushing.

Figure 4: A comparison of the lateral profile of the STb and Ormco-Kurz premolar
bracket. As before the brackets is bonded more occlusally. Also, the lower profile
and absence of a hook contributes to increased patient comfort.

Efficienttreatmentandreducedtreatmenttime
The benefits to the patient with respect to comfort are easily
demonstrated, however, the question that may arise is, How
effective are these brackets clinically?
The benefit of increased inter bracket distance
The lingual surface of the teeth has a reduced radius of curvature
compared to the labial surface. With the conventional Ormco-Kurz
brackets, due to their size, there is very little space between the
brackets when bonded correctly. The effects of the reduced inter

bracket width and decrease in the radius of curvature means that

it is more difficult to engage the initial aligning wire. An
undesirable high force if the arch wire is fully engaged may
increase patient discomfort and lead to fracture of the appliances.
The smaller size of the STb brackets tends to allow easier arch
wire engagement of a aligning wire of similar dimensions as the
inter bracket distance is reduced and furthermore, this leads to a
reduction in the forces applied to the teeth (Fig 2b).
The ability to engage the arch wire completely into the slot means
that three dimensional control of tooth movement is achieved
much earlier in treatment.
Placement of metallic ligatures
The utilisation of metal ligatures is recommended in orthodontic
treatment as it guarantees that the arch wire is placed firmly in the
bracket slot maximising the effect of the wire on the bracket and
the tooth. This procedure is laborious in the conventional lingual
technique using the Ormco Kurz brackets.
The placement of metal ligatures has been made significantly
easier with the STb brackets allowing the initial aligning phase to
be completed more easily (Fig 5).

Figure 5: The increased inter-bracket distance allows the wire to be fully engaged
into the bracket slot at the start of treatment

Reduced friction and light forces

The utilisation of metallic ligatures and light 0.010 or 0.012 nickel
titanium wires means that the forces applied to the teeth and
frictional resistance to movement is reduced (Fig 6). The
significance of these two factors is that there is more rapid
alignment of the teeth with reduced patient discomfort (Fig 7a-c)

Fig 6: The metal ligatures allow the wire to be fully engaged into the bracket slot
and reduce the friction for sliding mechanics

Fig 7 (a) First appointment appliances bonded; (b) 6 weeks after appliances
bonded; (c)12 weeks after the appliances bonded.

Greater ability to bond severely crowded teeth

A limitation of the increased dimensions of the Ormco- Kurz
brackets is that it is not always possible to bond all the teeth at the
start of treatment in a very crowded dental arch. This means that
placement of some brackets may need to be deferred, increasing
the time of the initial alignment phase of treatment and the overall
treatment time.
The reduced bracket size of the STb allows all the teeth to be
bonded at the start of treatment reducing the duration of the initial
phase of treatment and subsequent treatment
time (Fig 8).

Fig 8: Despite the rotations of the incisors it is possible to place all the
brackets at the initial appointment.

Use of elastics
The small size of the STb bracket and the absence of a hook do
not preclude the use of intra-oral elastics. Kobayashi ligatures may
be tied around the brackets to allow the patient to use intra-oral
elastics when it is necessary clinically (Fig 9).

Fig 9: Intermaxillary elastics may be attached to the Kobayashi ligatures

Laboratory procedure
1- Simplified technique
When torque control is not needed, a simplified technique
can be used. This technique uses only the initial model.
A line is traced on each tooth at the same distance from the
edge and the base of the brackets are bonded on this line.
Then a silicone transfer tray is used to make a full arch tray
or individual trays.
With this technique, only round wires will be used.

Fig 10 Simplified technique

2-B.E.S.T. technique ( Bonding with Equal Specific

B.E.S.T
. onding with Equal
B
S
pecific Thickness
system

Thickness) Fillion-1987
This technique allows to place the anterior brackets at the
same distance from the labial side and consequently
decrease archwire bending.

Fig 11 : Equalization of the distance from slot to labial side by

modifying the thickness of each resin pad.

Two devices are necessary : The T.A.D. ( Torque Angulation

device) to orientate the teeth in space and the B.P.D. ( Bracket
Positionning device) to place the brackets at a specific distance
from the labial side by modifying the thichness of each resin pad.
This technique must be used for all extraction cases and for nonextraction cases when torque control is necessary .

Fig 12 : Bracket Positionning device

Fig 13 : STb brackets with resin pad

3-Transfer Tray

Fig 14 : Resin Reinforced Silicon transfer tray

Bonding procedure
Because of the micro-sandblasting (25 microns of Aluminium
Oxyde - Airflow Prep K1- EMS), every surface can be bonded :
enamel, metal, amalgam, ceramic. Thanks to the Dry FieldSystem
( Nola Specialties, Inc.) every lower arch can be bonded in one
time.
Today bondings can be done with Maximum Cure ( Reliance
Orthodontic product ),Resin Reinforced Glass Ionomer Cement
( Fuji LC GC), FlowTain( Reliance Orthodontic products) with
OrthoSolo ( Kerr ) as liquide adhesive
The bonding procedure is similar to the procedure used to bond
Ormco- 7th generation brackets. Otherwise, it is recommended to
use unfilled resin or to use a minimum of bonding material to avoid
excess material blocked berween enamel and the occlusal part of
the bracket. This excess could prevent from ligating due to the
size of the bracket.

Fig 14 : Bonding with Nola on Lower arch

Archwire sequence
1- Non-extraction case
If any torque control necessary , only 2 or 3 wires will be
used :
Alignment-Leveling
.010 - .012 - .014, NiTi with
advancement loop if necessary
Detailing
.016 TMA
With torque control :
Alignment-Leveling
Torque control
Detailing

.010 - .012 - .014 - .016 NiTi

.017 x 017 CuNiTi
.0175 x .0175 TMA

2- Extraction case
Alignment-leveling
Partial cuspid retraction
Alignment-Leveling
Torque control
En Masse retraction
Detailing

.012 - .014 NiTi

.016 x .016 S.S.
.014 - .016 NiTi
.017 X .017 CuNiTi
0175 X .0175 TMA
Combination wire .018 x .
025 / .018
.016 TMA - .0175 x .0175 TMA

Ligating
It is essential to use metallic ligatures specially at the beginning of
the treatment with .010 and .012 NiTi. ( .08 or .09 ). In case of
severe crowding and rotation, it is useful to pull the wire with a
dental floss to engage the wire in the slot when ligating.

Efficiency of Low-Force / Low-Friction system

.012 NiTi

2 months later

.012 NiTi

2 months later

STb Bracket detail

STb bracket with 40 torque

STb bracket with 55 torque

Central/Lateral/Canine Upper
Central/Lateral/Canine Upper
Central/Lateral/Canine Lower
Premolars
1st Molar Upper Left
1st Molar Upper Right
1st Lower Molar
2nd Molar Upper Left
2nd Molar Upper right
2nd Lower Molar

Torque
Rot

Ang.

+40
+55
+40
+11
+10
+10
0
+10
+10
0

0
0
0
0
0
0
0
0
0
0

.014 NiTi with advancement loop

10
10
0
10
10
0

.014 NiTi is used with advancement loop to correct

anterior crowding

Retraction Mechanics
.018x .025 / .018 S.S.

CombinationWire

Sliding Mechanics

A Combination Stainless Steel wire is used for en masse

anterior retraction.The six anterior teeth are tied together as a unit
and then the 2nd premolar to the 1st and 2nd molars with a figureeight .09 steel ligature after inserting the wire.
An elastic thread is set from 2nd premolar to lateral .
Options:
the figure-eight ligature is placed before inserting the
wire and then an individual ligature is placed on each tooth after
inserting the wire.

Sliding Mechanics with Combination Wire

Frictionless Mechanics
Frictionless mechanics can be used with Bracket/Tube
( Fillion) bonded on 1st molars.
A curve of Spee and an anti-bowing effect form are incorporated
to the Combination wire.
1st option: FM1
NiTi springs are used in place of elastic thread from premolar to
lateral.
2nd Option: FM2
Lever arms are set between canine-lateral or between lateralcentral and between 2nd premolar- 1st molar.

3rd Option: FM3

Lever arms are set between canine and lateral when mini-screws
are used for anchorage.

Frictionless Mechanics with lever arms: FM2