Orthotown March 2020 - 38

Fig. 3

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38

significantly different from labial buccal
mucosa pain and can be managed well
with wax (especially at night) or other
temporary composite coverings. Remember
to tell patients that labial attachments will
be needed in many cases. If you have to
prescribe elastics, resolve crowding or bail
yourself out of a jam, you might need a labial
attachment or bracket. Make sure patients
are aware of this potential ahead of time.
Check the lingual surface of teeth
before you recommend lingual treatment.
The surface should be occlusal-gingivally
large enough for a bracket and free from
large extra cusps. It must be free of calculus buildup. You may want to perform
some enameloplasty pre-scan to allow for a
smoother bonding surface with the indirect
setup. Remind patients that they can't get
any dental treatment before the delivery of
the appliance, because of potential fit issues
it may cause. Finally, make sure patients
aren't getting married or having other major
life events the week after bonding for risk
of speech or discomfort issues.
Check all interproximal contacts after
bonding. Because the interbracket distance
is much shorter on the lingual side, it's

easier to get bonding and composite stuck
between teeth after lingual bonding, which
can compromise movement initially.
Especially for your first few lingual
cases, take photos at each visit and see
patients at least every month. I prefer to
work on just one arch at each appointment
and haven't found it slows the treatment
down. Having regular photos helps you
track progress more closely and plan for
future visits, which increases efficiency and
maximizes your chair time.
Finishing has always been one of the
most difficult parts of lingual treatment.
Because most of us were trained in a straightwire labial fi xed technique, we're used to
repositioning brackets for better finishing.
Repositioning of brackets is possible but
difficult with lingual, which places increased
reliance on the initial setup and virtual
treatment planning. The options for finishing
after repositioning brackets or standard
manual wire customization are rescanning
the patient for additional wires, labial
auxiliaries, or many doctors are finishing
cases with a few clear aligners. Again, make
sure you prepare yourself, your team and
your patients for the finishing and detailing
parts of treatment by planning ahead of time
which approach you'd like to take.

Caveats and limitations
*

As previously mentioned, lingual
treatment is "harder" than clear
aligner therapy from both a clinical
and patient perspective. Bonding clear
aligner attachments is much easier
than indirect fixed lingual bonding
of brackets. Understandably, clear
aligners are more comfortable than a
lingual fixed appliance. There are more
emergencies and oh-shoot-what-doI-do moments with lingual treatment.
But remember, grit. Always grit.

MARCH 2020 // orthotown.com

OT0320_Schofield_Lingual_AG.indd 38

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Orthotown March 2020

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