Biomechanics in lingual orthodontics:

What the future holds

D1X XRooz KhosraviD2X X

The field of orthodontics faced a few fundamental pivots since 1800. Edward
Angle introduced a systematic approach to treating patients in 1899.
Between 1920 and 2000, development of new orthodontic appliances as well
as improvements in orthodontics education reshaped orthodontics. Digital
technology has changed how orthodontists treat malocclusions in the last
two decades. Specifically, advances in digital orthodontics introduced a par-
adigm shift in lingual orthodontics attracting more orthodontists especially
recently graduated practitioners to offer lingual appliances. This review
aimed to point out some of important biomechanical factors in lingual ortho-
dontics and to delineate commonalities and contrasts of these factors in
clear aligners and labial systems. Highlights of two work in-progress lingual
systems were also discussed. One can reason that better understanding of
the advantages and challenges associated with lingual systems especially in
comparison to clear aligners and labial systems is essential to creating a fully
customized orthodontic experience for patients. (Semin Orthod 2018;
24:363–371) © 2018 Elsevier Inc. All rights reserved.

Introduction tooth movement remains the same. Therefore, a

T
solid understanding of tooth movement biome-
he field of orthodontics has significantly
chanics is essential to adapt to these constantly
changed during the last three decades. Digi-
changing appliances.
tal orthodontics allows practitioners to provide
In the last issue of Seminar in Orthodontics
individually tailored treatment modalities which
focuses on lingual orthodontics, Stuart McCros-
were a daunting task to accomplish not too long
tie (1937 2016) attributed the future of lingual
ago. Digital orthodontics is broadly referred to
orthodontics to three factors: (i) technological
systems harnessing digital imaging to assist with
advances in lingual appliances, (ii) growth in
diagnosing, simulating and treating malocclu-
adult orthodontics, (iii) orthodontists attitude
sion or skeletal deformities. Clear aligner therapy
toward lingual orthodontics.1 12 years later in
is indeed a great example on how digital ortho-
2018, we are significantly closer to the future of
dontics changed our daily practice by creating
lingual orthodontics that McCrostie described.
more interest in patients pursuing treatment
Three-dimensional imaging (and to some
especially adults. Lingual orthodontics, although
degrees three-dimensional printing) is the new
a less popular approach in the United States, has
normal in majority of orthodontic clinics. The
also been positively affected by digital orthodon-
use of lingual appliances is gaining popularity
tics. Digital indirect bonding has become the
among teenagers. Orthodontists’ attitudes
standard protocol for both customized and stock
toward lingual appliances are changing with
lingual bracket systems. Although all these tech-
recently graduated orthodontists showing a
nological advancements have changed how we
great interest in lingual orthodontics. Collec-
daily practice orthodontics, the biomechanics of
tively, lingual orthodontics is growing and there
is a need to build a larger community of lingual
Department of Orthodontics, School of Dentistry, University of orthodontics aficionados.
Washington, Box 357446, 1959 NE Pacific Street, Seattle, WA
Today, lingual orthodontic systems offer prac-
98195-7446, United States. E-mail: [email protected]
titioners three options: (i) stock (ii) fully custom-
© 2018 Elsevier Inc. All rights reserved.
1073-8746/12/1801-$30.00/0 ized, or (iii) a combination of stock and
https://doi.org/10.1053/j.sodo.2018.08.008 customized brackets and archwires. Stock

Seminars in Orthodontics, Vol 24, No 3, 2018: pp 363 371 363

364 Khosravi

brackets could be positioned on teeth by a com- in aligning the teeth by providing a longer lever
mercial or in-house laboratory. Traditionally, the arm3. Brackets can be customized to reduce
stock brackets are placed on stone models to fab- bracket width and increase inter-bracket width;
ricate indirect bonding trays. Digital orthodon- however this decreases the efficiency of the
tics has been slowly transitioning this process wire-bracket ligation mechanism.
into a computer simulated setup. Patients can It is equally important that the wire is fully
opt for customized brackets. Similar options exist engaged in the bracket slots for efficient and suc-
for lingual wires stock and robotically bent cessful alignment. This can often be challenging
wires. Each of these lingual systems has bio- with lingual appliances because of the complex
mechanical advantages and disadvantages in wire patterns and skill set required to ensure full
moving teeth. engagement of the wire. Self-ligating brackets
This review sought to identify some of impor- seem to offer an easier solution to this by making
tant factors in biomechanics of lingual orthodon- it easier to ensure full engagement of the wire
tics. Moreover, biomechanical similarities and and cutting down on chair time.
differences in lingual orthodontics are compared Comparing clear aligners, labial and lingual
with labial orthodontics and clear aligner ther- fixed appliances, esthetics is the main derive for
apy. I believe that analyzing these similarities and patients to opt for either clear aligners or lingual
differences among various systems provides a appliances. The flexibility to remove the appli-
deeper understanding on the efficiencies and ance at will is an advantage of clear aligners espe-
shortcomings of each system steering orthodont- cially in adult patients require long hours of
ists to remain dental specialists expert in moving verbal communications as a part of their daily
teeth rather than providers of appliance or sys- activities. Reduced daily hours of appliance wear
tem X. is unfavorable to treatment success.
Correction of severely misaligned teeth with
clear aligners requires significant numbers of
Advantages and challenges in lingual
aligners (average 2 3° of rotation per aligners).
orthodontics
Collectively, these factors make clear aligners an
Traditionally, a course of orthodontic treatment appliance a choice for patients with minor align-
is divided into multiple stages. This idea was ment problems and high compliance, while lin-
introduced by Raymond Begg with the premises gual appliances are more likely a better option in
to easier discuss the biomechanics pertinent to severely rotated teeth in noncompliant patients
each stage.2 Although the idea of moving teeth (Fig. 1).
in stages has been challenged with customized
appliances such as clear aligners or robotically
Leveling
bent archwires, I think it is still effective to discuss
biomechanics of orthodontics in the context of Intrusion and extrusion of the teeth using lin-
treatment stages. gual appliances results in overall less tipping in
when compared to labial systems because of the
shorter perpendicular distance to the center of
Alignment
resistance. Intrusion and extrusion of anterior
Inter-bracket distance, wire shape, size, and teeth with labially positioned brackets induce
materials, vertical position of brackets, and higher moment of force on these teeth which
wire-bracket ligation mechanics are factors to requires significant control of torque levels. The
optimize for efficient tooth movements during vertical position of brackets on the lingual surfa-
alignment stage. ces of the teeth affects the efficiency of intrusive
The primary challenge with aligning teeth and extrusive movements to level incisal edges
using a lingual bracket system is the inter-bracket and marginal ridges. Morphological heterogene-
distance. This is especially challenging when ity of the lingual tooth surfaces results in differ-
aligning arches with crowded lower anterior ences in slot angulation based on the position of
teeth where the inter-bracket distance is signifi- lingual brackets. Customized bracket bases con-
cantly reduced. Systems that provide longer trol for these changes to some degree (Fig. 2).
inter-bracket distances are overall more efficient Alternatively, lingual brackets can be positioned
 Biomechanics in lingual orthodontics: What the future holds 365

Figure 1. Inter-bracket distance is shorter in lingual orthodontic appliances. This illustration is a simplified repre-
sentation of distances between the point of force in lingual, clear aligner, labial appliances. (A) Lingual brackets
are positioned closer to the center of rotation hence rotational moment in lingual orthodontics is less compared
to labial brackets. Complete engagement of archwire in a crowded dentition is challenging because of small
inter-bracket distances. (B) Attachments facilitating alignment are placed labially in clear aligner appliances. It is
unclear whether a labially positioned point of force is favorable in an appliance that fully covers a tooth. (C) Lon-
ger inter-bracket distance in labial fixed appliances offers a better rotational moment.

more gingivally to minimize these morphological features such as pressure points on the lingual
differences. Gingivally placed lingual brackets surfaces of lower anterior teeth to enhance intru-
provides three main advantages: (i) the lingual sion of lower anterior teeth. The pressure points
surface morphology of teeth does not change feature mimics the biomechanics of lingually
moving from anterior to posterior teeth thereby positioned brackets and is a great example of
minimum 1st order bends. This is the core con- fundamental biomechanical principles amongst
cept behind straight-wire system4; (ii) reduced various orthodontic appliances.
chance of bracket interferences with the denti-
tion of opposing arch; (iii) biomechanical advan-
Space closure
tages. The main disadvantage of gingivally
positioned brackets in both lingual and labial sys- Space closure is frequently done by sliding
tems is difficulty maintaining good oral hygiene. mechanics. Patients interested in lingual applian-
Advantages of leveling biomechanics in lin- ces are often sensitive to esthetic aspects of treat-
gual systems are different in anterior teeth com- ment. Therefore, creating spaces between
pared to posterior teeth. Intrusion and extrusion anterior teeth should be avoided. This forces
with bracket positioned in center of lingual surfa- orthodontists to close extraction spaces via en
ces creates a greater unfavorable moment of masse retraction especially in the upper arch.
force during this movement. Gingivally posi- En masse retraction by lingually placed brack-
tioned brackets in the anterior teeth result in less ets is biomechanically more favorable compared
angulated direction of force which leads to bet- to sequential retraction of anterior teeth espe-
ter control of tipping during leveling extrusion cially when one uses mushroom archwires.5
and intrusion. The bracket position in posterior Retraction of the canines is difficult because of
teeth does not follow this notion due to lack of the premolars offset. Unfavorable retroclination
significant morphological changes in these of anterior teeth due to vertical bowing of the
teeth. archwire is the most common challenge in clos-
In comparison to lingually positioned brack- ing extraction spaces with En masse retraction.
ets, clear aligners are equally efficient at intrud- Several methods have been proposed to avoid
ing anterior teeth. Clear aligners intrude vertical bowing. Temporary mini screws can be
anterior teeth by inducing forces on surface area placed in the palate to provide absolute anchor-
located at the occlusal one third of the crown. age and prevent lingual tipping of the posterior
The Invisalign appliance provides additional teeth as a function of space closure. Additionally,
366 Khosravi

Figure 2. Bracket slot angulation changes based on the vertical position of a bracket on the lingual surface of a
tooth. Stock brackets positioned on the vertical mid-third lingual surface of a tooth express different torque levels
compared to the prescription torque in these brackets. Gingivally positioned brackets or fabricating customized
brackets are two approaches to avoid this problem.

a compensation curve can be placed in the arch- different types of wires are used to close spaces.8
wire to minimize vertical bowing.5 Today, automated robotic systems can be used to
The shorter inter-bracket distance of lingual bend these wires with high precision and accu-
systems in comparison to labial systems also pre- racy. In a finite element study recently published,
vents archwire bowing when closing spaces.6 This the authors compared helical and T-loop and
is an advantage allowing the use of archwires suggested that a T-loop in a titanium molybde-
with smaller dimensions, which is more comfort- num alloy (TMA) wire induces less force com-
able for patients, to close spaces in lingual appli- pared to a helical loop hence a more favorable
ances compared to labial appliances.7 force to moment ratio for translational move-
Frictionless (loop) mechanics is an alternative ment with limited uncontrolled tipping.9 Further
approach to close spaces with lingual appliances. studies to better understand the biomechanics of
In this method, various shapes of loops in added-features, like custom designed closing
 Biomechanics in lingual orthodontics: What the future holds 367

loops, into currently available lingual systems are lingual appliances at the early stages of treatment
required to optimize treatment time with lingual compared to labial appliances (Fig. 3).
orthodontics. The two main approaches that have been pro-
posed to overcome this issue are: (i) fabricating
custom brackets with optimized slot position
compensating for morphological heterogeneity;
Torque control
(ii) positioning brackets gingivally where tooth
It was alluded earlier that variations in lingual anatomical morphology is more uniform and
surfaces of teeth effects the vertical position of vertical positioning errors are minimized. Cus-
lingual brackets and control of torque by these tom-based brackets can eliminate the variation
brackets. As a result, it is common to encounter in morphology of tooth surfaces through individ-
torque discrepancy in the anterior teeth with ually designed brackets.

Figure 3. Vertical position of a bracket induces torque expression differently in labial and lingual fixed applian-
ces. Error in vertical position of customized lingual brackets placed closer to the tooth surface creates less torque
problems compared to stock lingual brackets positioned away from lingual surface of the tooth. Similarly, vertical
position errors in labial brackets positioning induce little to no torque issue. (A C) These three schematics
exhibit how the proximity to the center of resistance affect torque expression as a function of bracket positioning.
(D) Clinical representation of unfavorable torque expression in response to poor vertical bracket positing using
lingual appliances.
368 Khosravi

Figure 4. INBRACE lingual system is a new lingual orthodontic system using Smartwires and self-ligating brackets
to move teeth. (A) A schematic showing the components of INBRACE system. (B) INBRACE wire is a pre-
programmed 014 “NiTi Smartwire digitally designed to induce all three orders of movement according to the
patient virtual ideal occlusion. (C) Clinical picture of the upper arch with the INBRACE appliance (courtesy of
Dr. Hongsheng Tong). (D) These clinic progress photos are representing an extraction treatment plan with
INBRACE appliance with gable bend inserted in the third month of treatment. The space closure using the 016”
NiTi Smartwire is automated and does not need power chain or tieback activations (Courtesy of Dr. Andre
Weissheimer).

The precision of bracket slot dimensions as in brackets (archwire play) affecting the levels
well as archwire dimension affect torque con- of torque expressed by these brackets.11 More
trol in both lingual and labial systems.10 The studies on this topic in lingual orthodontics
manufacturing process to fabricate stock or are required to help practitioners understand
customized lingual brackets influences the challenges in controlling torque with various
degree of accuracy and better fit of archwires systems.
 Biomechanics in lingual orthodontics: What the future holds 369

Figure 5. A new developing lingual system (Mechanodontics system) using a rigid bar with flexible fully custom-
ized arms. In this system finite element modeling is used to define the ideal path of tooth movement for each indi-
vidual tooth based on the desired planned therapeutic outcome. (A) A rigid bar and flexible fully customized arms
are the main components of the Mechanodontics system. (B) The shape and thickness of each arm is designed
according to the required force to create the movement based on the therapeutic digital setup. (C) Clinical exam-
ples of the Mechanodontics system during treatment (courtesy of Dr. Mehdi Peikar).
370 Khosravi

Lingual systems in progress daily practice, lingual orthodontics assists with

providing care to a segment of the population
Along with advances in orthodontic appliances,
that would otherwise not seek out orthodontic
new customized lingual systems are entering the
treatment. Over two decades later, lingual ortho-
market and traditional systems are adapting to
dontics is facing the same criticism of whether the
digital orthodontics. For example, the Orapix sys-
extra efforts are worth it. I think advances in lin-
tem, introduced in 2011, was developed to create
gual appliances will continue reducing the efforts
a digital platform for positioning lingual brackets
require to deliver lingual orthodontics. Addition-
which was traditionally prepared on physical
ally, further public awareness on orthodontic
models.12 Most of lingual appliances including
treatment especially by companies providing
the digital customized brackets and archwires
direct to consumer clear aligners increases the
technique introduced by Weichmann et al. in
number of individuals seeking esthetic orthodon-
20037 are now fabricated based on digital setups
tic treatment options. These create an optimistic
from digitally acquired dental models.n
future for lingual orthodontics.
A recently trending system called INBRACE intro-
Better understanding of biomechanics in lin-
duced a new approach to lingual orthodontics. This
gual orthodontics helps utilizing new technology
system uses customized multi-looped archwires to
to enhance lingual appliances. Majority of ortho-
induce tooth movement with infrequent activation
dontists did not predict the domination of clear
of archwire. INBRACE system uses a self-ligating
aligners in 1999 when the Invisalign appliance
non-sliding mechanics aiming to reduce clinical
was introduced to the market. Biomechanical
adjustment during the course of treatment as well
knowledge of labial orthodontics was used, cor-
as to minimize the use of auxiliary appliances such
rectly or incorrectly, to develop and enhance
as closing elastomeric chain (Fig. 4).
clear aligner therapy. What we learned about bio-
Additionally, a newer under-development lin-
mechanics of clear aligners can be transferred to
gual system (US Patent: US20170156823A1) is
lingual orthodontics to shape the future of
claiming to create simultaneous three-dimen-
esthetic orthodontics in which lingually posi-
sional tooth movement. In another words, this
tioned fixed appliances has so much to offer.
system proposes combining tooth movements in
various stages of treatment into a one efficient
path of movement. The components of this lin- References
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arms made of nickel titanium, which attaches to Orthod. 2006;12(3):211–214.
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required force and moment to induce tooth relevance to orthodontic treatment. Eur J Orthod. 1995;17
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 Biomechanics in lingual orthodontics: What the future holds 371

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