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DOI: 10.1051/odfen/2011405 J Dentofacial Anom Orthod 2012;15:105 Ó RODF / EDP Sciences 1 Conflicts of interest declared by author: cf. at end of article Received: 08-2011 Accepted: 10-2011 Customized brackets and the straight arch technique combined in one appliance to simplify lingual orthodontics Pascal BARON, Christophe GUALANO ABSTRACT The concept of the appliance we describe in this article is based on a number of technological advances. The brackets, created in accordance with CAD/CAM are the product of an original process that makes them resistant to de-bonding providing a high resistance to bracket loss. They are also compatible with the use of a veritable straight wire enabling the use of pre- fabricated standard wires. The manufacturing process uses a maximum of digitized resources to elaborate a numerical set-up usable by the practitioners. A 3D computerised treatment control is performed from the beginning to the end of the assembly line and warrants a perfect precision of the bonding placement. Appliances are completely personalized for each patient taking into account particular anatomic features as well as the prescriptions of practitioners. As a result practitioners will benefit from a number of theoretical advantages making treatment more pleasant and functionally smoother at every phase of therapy. Managing the Lingualjet appliance is simple and transforms straight wire lingual therapy into a procedure comparable in every way to traditional use of the straight wire in buccally bonded attachments. KEY WORDS Lingual orthodontics, CAD, CAM, Straight wire, Digital set-up, 3D imaging. Address for correspondence: P. BARON Department of Orthodontics University of Toulouse III 3 Chemin des Maraichers, 31062 Toulouse Cedex 4 [email protected] Article available at http://www.jdao-journal.org or http://dx.doi.org/10.1051/odfen/2011405

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Page 1: Customized brackets and the straight arch technique ... · PDF fileCustomized brackets and the straight arch technique combined in one appliance to simplify lingual orthodontics

DOI: 10.1051/odfen/2011405 J Dentofacial Anom Orthod 2012;15:105� RODF / EDP Sciences

1

Conflicts of interest declared by author: cf. at end of articleReceived: 08-2011Accepted: 10-2011

Customized brackets andthe straight arch techniquecombined in one applianceto simplify lingual orthodontics

Pascal BARON, Christophe GUALANO

ABSTRACT

The concept of the appliance we describe in this article is based on anumber of technological advances. The brackets, created in accordance withCAD/CAM are the product of an original process that makes them resistant tode-bonding providing a high resistance to bracket loss. They are alsocompatible with the use of a veritable straight wire enabling the use of pre-fabricated standard wires. The manufacturing process uses a maximum ofdigitized resources to elaborate a numerical set-up usable by the practitioners.A 3D computerised treatment control is performed from the beginning to theend of the assembly line and warrants a perfect precision of the bondingplacement.

Appliances are completely personalized for each patient taking into accountparticular anatomic features as well as the prescriptions of practitioners. As aresult practitioners will benefit from a number of theoretical advantagesmaking treatment more pleasant and functionally smoother at every phase oftherapy. Managing the Lingualjet appliance is simple and transforms straightwire lingual therapy into a procedure comparable in every way to traditionaluse of the straight wire in buccally bonded attachments.

KEY WORDS

Lingual orthodontics,

CAD,

CAM,

Straight wire,

Digital set-up,

3D imaging.

Address for correspondence:

P. BARONDepartment of OrthodonticsUniversity of Toulouse III3 Chemin des Maraichers,31062 Toulouse Cedex [email protected] available at http://www.jdao-journal.org or http://dx.doi.org/10.1051/odfen/2011405

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If one reviews the history of thelingual orthodontic technique since itwas introduced about 1982 and afterFujita presented the mushroom arch,one notices that most technical andtechnological advances adopted inthe field of orthodontics were firstdesigned for use in lingual therapy.This can be seen as a result of lin-gual practitioners being by nature re-ceptive to innovation or, perhapsmore accurately, because lingualorthodontics is a discipline that isnever perfected and whose adeptsare perpetually searching for solu-tions to its reliability problems. Sucha review would also indicate that un-til about 2005 almost all articles weredevoted to techniques, proposingnew appliance systems or laboratorymethods.

In this orthodontic arms race com-puters will be playing an increasinglyprominent role propelled by the rapidrise of use and power of information

technology throughout our society.And, it should be noted, these devel-opments coincide with a revival of in-terest in lingual orthodontics, which,until very recently, had been gravelyweakened by a loss in the alreadysmall number of its adherents. Sothe time is ripe for conception as-sisted by computer, CAC, to takeits place in the formation, first of allof arch design promoted by systemslike BEST (Bonding with EqualSpecific Thickness); DALI (Dessind’Arcs Lingual Informatise) (1989);TOP (Transfer Optimized Positioning)(1998). Next came the concept ofcustomized bracket with Incognito(2003) and digitalized set-up withOrapix (2005). Finally, in 2009 Lin-gualjet introduced an appliance thatis created in every step of its con-struction and application by computerprograms (fig. 1).

Takemoto and Scuzzo8 proposed alingual version of the straight wire

Figure 1Technological forward leaps in lingual orthodontics (sources < 2010 patents and publications).

PASCAL BARON, CHRISTOPHE GUALANO

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technique in 2001 but this techniqueremained unused in the conceptualstage for many years because tech-nologies of the time were not cap-able of implementing it. Howeverthese two orthodontists9 were ableto partially overcome the compatibil-ity problems that industrially pro-duced brackets posed for executionof their straight wire lingual conceptby fabricating a series of brackets ofsmaller size with a re-designed pro-file.

Customized brackets had, however,already been introduced in 2003 in con-formity with a conservative philosophywhere the arch wires remained underthe control of a robot. Fontanelle haddevised in 1983, long before the era ofwidespread computer technology ap-plications, the original scheme for per-sonalized lingual attachments providedby metal casting method to performthe first customized lingual orthodontictreatments in France (fig. 2). Muchlater, Weichmann10 proposed a pro-cess consisting of the fabrication of

made-to-measure computerized three-dimensional brackets cast in a gold al-loy to receive a sequence of arch wiresalso computerized. This apparentlyuser-friendly appliance made a majorcontribution to the development of lin-gual orthodontics by enticing a greatnumber of orthodontists to employ lin-gual techniques.

So by 2007 orthodontists couldchoose to work with a straight wireand commercial brackets constructedwith limited capability of adapting toconditions of anatomic variations ofarch forms and of the lingual sur-faces of teeth or of using 3D brack-ets coupled with robotized arch wiresincorporating bicuspid insets thatgave them an initial mushroomshape. In 2008 the first beta versionof the Lingualjet appliance was intro-duced and presented at the EuropeanSociety of Lingual Orthodontics(ESLO) convention. With it, for thefirst time orthodontists would be ableto use a standard form straight archwire in computer generated brackets

Figures 2a and 2ba: customized brackets on first and second molars;b: production notes on the author’s manuscript.

CUSTOMIZED BRACKETS AND THE STRAIGHT ARCH TECHNIQUE COMBINED IN ONE APPLIANCE TO SIMPLIFY LINGUAL ORTHODONTICS

Rev Orthop Dento Faciale 2012;15:105. 3

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totally adaptable to accommodatingthemselves perfectly to the exigen-cies imposed by variations in dental

surfaces and the special needs ofthe straight wire technique.

1 – SPECIAL FEATURES OF THE LINGUALJET TECHNIQUE

The basic conceptions of the Lin-gualjet appliance are drawn from anumber of technological advance-ments3.

1 – 1 – A digitized setup

Without being, as yet, able to em-ploy the optical impression techni-ques that will soon be available, wedigitize plaster models of a patient’sdentition with a very high-resolutionoptical scanner. Then a digitized set-up is constructed for the finishedcase including anticipated inter andintra-arch relationships as well as anyspecific prescriptions such as over-correction, augmented torque or tip-ping, anchorage preparation, andothers. These operations are accom-plished on the computer screen by

means of special programs. The prac-titioner validates this working modelthat can, when desired, import theset-up computer file into any desired3D program (fig. 3). The conventionalviews that thus become available arefrontal, profile, and occlusal consti-tute an alternative means for practi-tioners to validate the quality of thevirtual occlusion .Once validated thesetup will be the working modelused for the assembly line.

1 – 2 – Customized brackets

All attachments, constructed vir-tually with computer assisted tech-nology, are individualized to fit theteeth to which they will be bonded.Their bases present a large extendedsurface adapted to fit intimately with

Figure 3Digitized set-up of a four second bi-cuspid extraction case performedand filmed by MeshLab@ that canbe viewed in 3D from every angleand at any desired enlargement.

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the anatomy of the teeth they arejoined to. All bracket slots acceptedgewise arch wires and are alignedon a virtual straight arch wire thatpasses as closely as possible alongthe lingual bulges of the ensemble ofteeth in the arch. The positioning ofthe body of the bracket on its basescan vary in all directions to allowwide latitude of adaption to initialconditions. The individualized brack-ets all have rounded forms and lesspronounced contours (fig. 4). Whenall the virtual attachments are com-pleted they are exported to be con-verted into a plastic physical realitythat can be burned out when cast-ings of them are made in an alloy ofgold, essentially Au + Pd +Ag, whichhas remarkable properties with coef-ficients of elasticity (Young’s Modu-lus = 75 GPa) that are very close tothat of enamel (Young’s Modulus =82 Gpa). To give an idea of how ef-fective they are, composites that al-low on the average a compensatoryheel during the positioning of pre-fab-ricated attachments are much morevulnerable to deformation (E << 10Gpa) and, as a direct consequence,to becoming detached. Moreover,

the bases of LJbrackets are piercedwith special perforations made by anoriginal fabrication procedure that in-creases resistance to debonding byimproving retention thanks to betterphoto-polymerization of the bondingmaterial2. Finally, the size of theLJbracket has been reduced enoughto make it comparable in size to themost diminutive commercial bracketsavailable today (fig. 4).

1 – 3 – The straight arch

The system’s straight wire can beadjusted slightly in the sagittal planeand its horizontal plane positionedmore gingivally so that the differencebetween the canine cingulum and thelingual surface of the premolar will bein continuity without placement of theslightest arch wire in-set. The archwire is placed as close as possible totooth surfaces and it is formed in ac-cordance with the disposition of thecrown lingual surfaces at its level. Thisis re-transcribed on a chart that de-scribes the intersection of the archwith the center of each bracket slot(fig. 5).

Figure 4Size comparison between an STb social-6bracket and a Lingual-Jet LJ bracket. Note thatthe placement of bonding material on pre-fabri-cated brackets necessitates placement of addi-tional composite material when it is mountedin the laboratory.

CUSTOMIZED BRACKETS AND THE STRAIGHT ARCH TECHNIQUE COMBINED IN ONE APPLIANCE TO SIMPLIFY LINGUAL ORTHODONTICS

Rev Orthop Dento Faciale 2012;15:105. 5

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The use of the made-to-measure3D bracket makes arch wire standar-dization in a single form possible.From this standardized start, practi-tioners are free to select any type ofarch wire needed in the material andsize desired for the phase of treat-ment in progress, just as they wouldin any veritable straight wire techni-que.

Its one-piece bracket design with awidely distributed bonding surface,its capability of varying slot height tosuit needs, and its allowance for ad-justments of position between bodyand base allow the LJ bracket to ad-just to the geometric exigencies de-manded by the lingual straight wiretechnique. In doing so, the arch wireis closer to the center of resistanceof the tooth, which gives orthodon-tists a highly desirable increase intherapeutic control. Obtaining the an-ticipated result depends on the preci-sion of the fabrication, which, if it is

optimum, will reproduce in the pa-tient the exact changes made in thesetup (fig. 6).

1 – 4 – 3D dentofacialimaging

If it seems desirable to extend theparameters of the LJ appliance,orthodontists have the option of as-sembling supplementary data. Today,Cone Beam, computed axial tomo-graphy, technology makes volumetricradiological assessments readily avail-able, giving orthodontists three-di-mensional films and producingdiagnostic and treatment aids like, forexample the Cepha3DT view andanalysis portrayed in figure 7. It isnow also possible to enrich the preci-sion of the setup by including theroots in the working space and to as-sure, with certainty, intra-arch rootparallelism as well as the angular re-

Figures 5a and 5ba: LJ arch chart;b: design of the straight wire arch: for each bracket the center of the slot is representedon the chart by its intersection by the line of the arch.

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lationships between antagonisticteeth in the two arches (fig. 8). Thisoption allows orthodontists to push

the envelope still further in the direc-tion of accurate individualization ofthe appliance by incorporating sup-plementary anatomic data.

Figures 6a to 6ca: digital setup;b: appliance design;c: result in the mouth after alignment and leveling.

Figure 7This Cone Beam imaging technique gives orthodon-tists the capability of reproducing virtual facial, skele-tal, and dental structures and utilizing biometricanalysis tools like Cepha3DT.

Figure 8Roots can be reattached to their crowns in a virtualsetup of the entire dentition. In this view, to makethe image more readable, only every other tooth ispictured with its crown-root axis.

CUSTOMIZED BRACKETS AND THE STRAIGHT ARCH TECHNIQUE COMBINED IN ONE APPLIANCE TO SIMPLIFY LINGUAL ORTHODONTICS

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2 – TRANSFERRING THE ATTACHMENTS TO THE MOUTHAND BONDING THEM

In any transfer of orthodontic at-tachments to the mouth the ortho-dontist’s primary goals are to assureboth maximal precision in their place-ment and optimal quality of theirbonding to make them highly resis-tant to detachment. These principlesapply with, perhaps, greater vigor tolingual than to buccal appliances. Lin-gually, difficulties are aggravated andevery instance of imprecision of pla-cement or loss of a bracket will re-sult in a mal-positioning tooth thatwill have to be corrected in finishingprocedures7.

Many details of the conformationof the LJbracket base increase theefficacy of their bonding:– absence of a composite mounting

heel;– an enlarged surface constructed to

fit the surface contours of the toothto which it will be attached;

– intimate juxtaposition of tooth sur-face and bracket base, augmentingstability;

– presence of LJ pores that bothimprove retention in leaving ex-truded composite buttons (fig. 9)and facilitate better polymerizationof the bonding agent by letting lightpenetrate to the bracket base.

– One of the advantages customizedattachments is that they give ortho-dontists the option of bonding themdirectly. Because their bases aredesigned to perfectly fit the dentalsurface they are destined to join inan exactly specified position, ortho-dontists can bond directly to thelast molar in an arch when accessto it has improved or rebond a

detached bracket as easily as theywould a detached buccal bracket.However, as a rule bonding ofattachments lingually to an entirearch is carried out in a singleprocedure with a two-layer transfertray that provides all the neededcapabilities. The first layer, contact-ing tooth surfaces, carries thebrackets to be bonded firmly inthe material, which is translucentand supple enough to allow easyand non-aggressive removal afterbrackets have been attached toteeth. On top, a 0.5 mm thicktransparent acrylic envelope con-fers to the full arch assembly therigidity needed for the tray’s intro-duction into the mouth, its correctapplication to the teeth, and ease ofits maintenance in place during thefull period of polymerization.

Figure 9The LJpores significantly increase the quality of thebonding process.

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The final position of the brackets,which have themselves been digitallydesigned on the digital setup, in thetransfer tray is controlled by a digitalCDA program (fig. 10 through 12).Once created, these virtual bracketswill again be attached to the digitalmodel representing the initial plannedalteration of the arch. This file will then

be exported via a rapid prototype thatwill reconstitute in plastic the threedimensional impression of the originalmodel with the brackets. It will consti-tute the working model for the trans-fer tray that will be fabricated on it.The brackets, cast in metal, will becarefully placed in their respective trayslots, ready for bonding.

Figures 10a and 10ba: virtual brackets attached to initial virtual model;b: plastic working model made from virtual model.

Figures 11a and 11ba: real brackets set in transfer tray;b: bonding by polymerization.

CUSTOMIZED BRACKETS AND THE STRAIGHT ARCH TECHNIQUE COMBINED IN ONE APPLIANCE TO SIMPLIFY LINGUAL ORTHODONTICS

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3 – CLINICAL CASE (fig. 13 to 21)

Mr. Alexandre C. is a 24 year-oldprofessional who had no previousorthodontic treatment. He consultedus because of his ‘‘crooked teeth’’and uncomfortable occlusion, desir-

ing treatment with an appliance thatwould not be visible.

Our most salient clinical findingswere his asymmetrical occlusal rela-tionships, Class III on the right and

Figures 12a to 12ca: removal of the acrylic coverb: peeling off the elastic layerc: result of the transfer tray’s having been held rigorously in position – brackets will be attached to the four bicus-pids later when they will be included in the treatment.

Figures 13a to 13cPre-treatment facial views.

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Figures 14a to 14cIntra-oral views showing the occlusal asymmetry and the anterior crowding in both arches.

Figures 15a and 15bPre-treatment radiographs.

CUSTOMIZED BRACKETS AND THE STRAIGHT ARCH TECHNIQUE COMBINED IN ONE APPLIANCE TO SIMPLIFY LINGUAL ORTHODONTICS

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Figure 16a to 16eTreatment stages in the correction of

alignment and rotations in the upper arch.

Figure 17a to 17cAlignment of the lower arch.

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Figures 18a and 18bPost-treatment radiographs.

Figures 19a to 19ePost-treatment intra-oral views.

CUSTOMIZED BRACKETS AND THE STRAIGHT ARCH TECHNIQUE COMBINED IN ONE APPLIANCE TO SIMPLIFY LINGUAL ORTHODONTICS

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Class II on the left, a midline devia-tion, and upper and lower anteriorcrowding. The upper left buccal teethwere in a mesial position that ex-tended to the right central incisor.The lateral sectors of both archeswere compressed toward the lingual.Skeletally, his face is balanced butthe upper right buccal teeth are inmesioversion.

Our treatment plan proposed an in-itial leveling and alignment of theteeth in both arches followed by

asymmetrical mechanics supportedby miniscrew anchorage to be com-pleted by detailed intermaxillary fin-ishing.

We constructed a Lingualjet ver-sion 1.3beta appliance and bonded itinto both arches, differing bonding ofthe upper right lateral to a later pointin treatment when its lingual surfacewould be more accessible. Figure 16shows steps in the alignment and ro-tation correction of the upper archachieved with the aid of an elastic

Figures 20a to 20cPost-treatment facial views.

Figures 21a to 21cThe setup is a virtual duplicate of the result achieved in the mouth.

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worn on the left side only to a mini-screw anchor placed mesial to theupper left second molar.

A treatment time of 23 monthswas required for us to obtain satis-factory alignment of the crowns andparallelism of the roots.

The sequence of the arches weemployed was limited to these: .016NiTi/ .018 NiTi/.018 by .018 NiTi/.016by.022 TMA.

We corrected antero-posterior archrelationships and brought the archesinto transverse harmony by letting asuccession of straight arch wires ofprogressively increasing size gradu-ally express their corrective force onthe teeth.

The result we obtained, with nobracket detachment throughout treat-ment, corresponds almost exactly toour original predictive (and working)setup. Today, Lingualjet 2.1, the latestversion of our appliance, allows ortho-

dontists to undertake treatment with asystem of attachments that are smal-ler and more precise than any thatwere previously available. Orthodon-tists retain complete freedom of se-lecting options from the time theywrite the original prescription untilthey remove the appliance thanks totheir use of a veritable straight archwire supported by 3D digitized brack-ets that carry within them the totalityof information needed for every treat-ment phase. The Lingualjet system isparticipating in the advancement oflingual orthodontic therapy by makingit simpler, more comprehensible, andby not requiring orthodontists to modi-fy their working methods or compro-mising their convictions. Practitionerstoday can achieve the same results byworking ‘‘inside’’ that they have beenaccustomed to producing by concen-trating on the ‘‘outside.’’

REFERENCES

1. Baron P, Gualano C. Anchorage control performed with mini-screws and the Lingual-jet Appliance. In: Echarri P, Takemoto K et al. Nuevo Enfoque en Ortodoncia Lingual,Madrid: Ed. Ripano, 2010:15-26.

2. Baron P, Gualano G, Sempe L, Sciacca AJ, Hall G. The Manufacturing Process forLingualJet in: Romano R (ed). Lingual and esthetic orthodontics. Chicago: Quintes-sence Publishing, 2011:167-80.

3. Baron P, Gualano C. The LingualJet Appliance: a one-piece customized bracket com-bined with a straightwire technique. Clinical Review 2011:44-9.

4. Cem Caniklioglu M, Ozturk Y. Lingual orthodontics: treatment of non extraction case.Intern Orthod 2005;3:76-86.

5. Fillion D. Computer generated conception and fabrication of transfer trays for indirectbonding of lingual attachments: The Orapix system. Rev Orthop Dento Faciale2007;41:61-75.

6. Gallettie C, Mujagic M, Simon JS. Orthodontie linguale : positionnement du premierarc dans la zone anterieure. Intern Orthod 2007;5:301-26.

CUSTOMIZED BRACKETS AND THE STRAIGHT ARCH TECHNIQUE COMBINED IN ONE APPLIANCE TO SIMPLIFY LINGUAL ORTHODONTICS

Rev Orthop Dento Faciale 2012;15:105. 15

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7. Sattler NA. Bonding and rebonding; A small problem with a big effect in lingual tech-nique. Intern Orthod 2005;3:329-37.

8. Takemoto K, Scuzzo G. The straight-wire concept in lingual orthodontics. J ClinOrthod 2001;35:46-52.

9. Takemoto K, Scuzzo, Lombardo L, Takemoto Y. Lingual straight wire method. InternOrthod 2009;7:335-53.

10. Wiechmann D. The new Top bracket: a step forward in lingual orthodontics? InternOrthod 2003;1:119-38.

DECLARATION OF CONFLICT OF INTEREST

I, the undersigned, Pascal Baron, that the authors of this article entitled:‘‘Customized brackets and the straight wire technique combinedin one appliance to simplify lingual orthodontics’’Pascal Baron and Christopher Gualano

are participating owners of the Lingualjet Orthodontics Company that developed the Lingualjet appli-ance, which is described in this article submitted for publication to the Revue d’Orthopedie Dento-Faciale.

Toulouse 16/10/2011P. Baron

PASCAL BARON, CHRISTOPHE GUALANO

16 Baron P., Gualano C. Customized brackets and the straight arch technique combined inone appliance to simplify lingual orthodontics