Printer Friendly

Lingual Treatment of an Adult Patient with a Simplified Extraction Protocol.


Visible orthodontic appliances are challenging for adult patients. In a recent study, 33% and 62% adults refused orthodontic treatment using a visible appliance (1). With the increasing esthetic demands of adult patients, lingual orthodontics and clear aligners have recently become popular (2). Lingual orthodontics provides the best esthetic option for complex cases with three-dimensional control (3). Customized lingual appliance systems have improved patient comfort, provided accurate bracket positions, and produced similar treatment outcomes as labial orthodontics.

The objective of this case report was to present the treatment results of an adult patient treated with extraction using fully customized lingual brackets.


A male patient 43 years 4 months of age was referred to our clinic with the chief compliant of dental crowding. Diagnostic records showed that he demonstrated Class II molar and canine relationships on the left side and Class I canine relationship on the right side with retrusive upper, protrusive lower incisors, normal overjet, and mildly increased overbite (Figure 1, 2). Upper right first molar had previously been extracted. There was an ectopic canine tooth with an unesthetic veneer crown on the upper left quadrant. According to dental cast analysis, dental arch discrepancies were measured as 9.2 mm in maxilla and 4 mm in mandibula. Cephalometric measurements are presented in Table 1.

Treatment goals were to eliminate dental crowding, obtain Class I canine relationship on both sides, and also achieve ideal overjet and overbite. The treatment plan was to extract the buccally positioned upper left canine and use upper left first premolar as canine substitution. The color and shape of the premolar were noted as suitable for the canine substitution. A dental implant was planned for replacing the upper right first molar. Written informed consent was obtained from the patient.

Treatment Sequence

Fully customized lingual brackets (Incognito, TOP service, 3M Unitek, Bad Essen, Germany) were manufactured according to the patient's impressions and a digital setup was created (Figure 3). After the bonding of brackets, upper left canine was extracted. The arch-wire sequence was .014" SE (super-elastic) nickel titanium for levelling and alignment; .016"x.022" SE nickel titanium, .018"x.025" SE nickel titanium for correcting rotations and providing initial torque control; .016"x.024" stainless steel for torque control, and .018"x.018" TMA (titanium-molybdenum alloy) for finishing. Interproximal reduction was performed for the crowding of the mandibular anterior teeth during the treatment. An attempt was made to achieve mesial movement of the upper right second molar, but it failed due to pneumatization of the maxillary sinus. The patient refused to undergo a sinus lift surgery.

At completion of the treatment, Class II molar relationship on the left side and Class I canine relationships on both sides were obtained; also, a balanced and ideal occlusion was achieved (Figure 4). Post-treatment cephalometric radiographs are shown in Figure 5. Total treatment duration was 2 years and 8 months. Throughout this period, the attempt for molar mesialization took 10 months. After debonding, fixed retainers were bonded, and additional essix plates were fabricated for both arches. The cephalometric parameters for pre- and post-treatment are shown in Table 1. The superimposition of pre- and post-treatment lateral cephalometric radiographs showed the extrusion of upper molar and proclination of lower incisor (Figure 6).


The demand for adult orthodontic treatment has progressively increased in recent years, and reportedly 25% of orthodontic patients were adults in United States (4). A previous study showed that 90% of adult orthodontic treatments required fixed appliances (5).

Customized lingual orthodontics is the most esthetic option for adult patients with three-dimensional control, and it is suitable for all types of malocclusions. Improved digital technology of customized lingual systems helps create a virtual set-up, customized bracket positioning, arch-wire, and bracket fabrication. These steps facilitate improvement in the of the treatment outcomes.

Adults generally have restored or endodontically treated teeth, which can complicate the treatment plan. In the patient in the present study, we extracted the buccally positioned upper left canine using endodontic treatment for correcting the dental crowding. We used upper left first premolar as canine. In literature, premolars are often used instead of canines, and it was suggested that premolars would effectively enhance esthetics in cases of orthodontic space closure (6, 7).

The upper molar was attempted to move mesially but because of the pneumatization of the maxillary sinus, this movement was not completed. Teeth can be moved if there is adequate bone in the direction of movement and it is challenging to move teeth through anatomic limitations such as maxillary sinus, sutural, or cortical barriers.


The treatment of adult cases with high esthetic concerns can be effectively performed using customized lingual brackets. Customized lingual appliance systems have the ability to treat complex cases, and advanced digital technology can help clinicians plan all the treatment steps.

Informed Consent: Written informed consent was obtained from the patient who participated in this study.

Peer-review: Externally peer-reviewed.

Author Contributions: Concept - o.P.o., H.P.; Design - o.P.o., H.P.; Supervision - o.P.o., H.P.; Resources - o.P.o., H.P.; Materials - o.P.o., H.P.; Data Collection and/or Processing - o.P.o., H.P.; Analysis and/or Interpretation - o.P.o., H.P.; Literature Search - o.P.o., H.P.; Writing Manuscript - o.P.o., H.P.; Critical Review - o.P.o., H.P.

Conflict of Interest: The authors have no conflict of interest to declare.

Financial Disclosure: The authors declared that this study has received no financial support.


(1.) Meier B, Wiemer KB, Miethke R-R. Invisalign Patient Profiling. J Orofac Ortho 2003; 64: 352-8. [CrossRef]

(2.) Fritz U, Diedrich P, Wiechmann D. Lingual technique - Patients' characteristics, motivation and acceptance. Interpretation of a retrospective survey. J Orofac Orthop 2002; 63: 227-33. [CrossRef]

(3.) Echarri P. Revisiting the History of Lingual Orthodontics: A Basis for the Future. Semin Orthod 2006; 12: 153-9. [CrossRef]

(4.) Gottlieb EL, Nelson AH, Vogels DS. 1991 JCO orthodontic practice study. 2. Practice success. J Clin Orthod 1991; 25: 740-7.

(5.) Khan RS, Horrocks EN. A study of adult orthodontic patients and their treatment. Br J Orthod 1991; 18: 183-94. [CrossRef]

(6.) Zachrisson BU, Rosa M, Toreskog S. Congenitally missing maxillary lateral incisors: Canine substitution. Am J Orthod Dentofac Orthop 2011; 139: 434-44. [CrossRef]

(7.) Sharma PK, Sharma P. Interdisciplinary management of congenitally absent maxillary lateral incisors: Orthodontic/prosthodontic perspectives. Semin Orthod 2015; 21: 27-37. [CrossRef]

omur Polat ozsoy (1) 1D, Hande Pamukcu (2) 1D

(1) Department of Orthodontics, Cyprus Health and Social Sciences University School of Dentistry, Guzelyurt, Cyprus

(2) Department of Orthodontics, Baskent University School of Dentistry, Ankara, Turkey

Address for Correspondence: Hande Pamukcu, Department of Orthodontics, Baskent University School of Dentistry, Ankara, Turkey


Received: 3 January 2018

Accepted: 25 February 2018

ORCID IDs of the authors: o.P.o. 0000-0002-8555-1367; H.P. 0000-0003-4242-5114.

DOI: 10.5152/TurkJOrthod.2018.17061

Cite this article as: Polat Ozsoy O, Pamukcu H. Lingual Treatment of an Adult Patient with a Simplified Extraction Protocol. Turk J Orthod 2018; 31: 62-6.
Table 1. Pre- (T0) and post-treatment (T1) cephalometric measurements

                          Norm Values   T0     T1

Sagittal Analysis
SNA ([degrees])            80[+ or -]2   78.5   77.5
SNB ([degrees])            78[+ or -]2   74.6   74.2
ANB ([degrees])             2[+ or -]2    3.9    3.1
GoGnSN ([degrees])         32[+ or -]6   27.5   28.5
Gonial Angle ([degrees])  130[+ or -]7  111    111
Dental Analysis
U1 -NA (mm)                 4             3      4
U1-NA ([degrees])          22[+ or -]5   12.5   16
L1-NB (mm)                  4             5.1    5.3
IMPA ([degrees])           90[+ or -]3  102    106
Overjet (mm)                3             3.5    2.8
Overbite (mm)               3             4      2.8
Soft Tissue Analysis
Upper Lip-E Line (mm)
Lower Lip-E Line (mm)      -4            -6     -5
                           -2            -6     -4.4

SNA: Sella-nasion-A point angle; SNB: Sella-nasion-B point angle; ANB: A
point, nasion, B point; GoGnSN: angle that is measured at the junction
of the planes Gonion to Gnathion and Sella-Nasion; IMPA: incisor
mandibular plane angle; U1-NA ([degrees]): angle between upper incisor
inclination and NA plane; L1-NB ([degrees]): angle between lower incisor
inclination and NB plane
No portion of this article can be reproduced without the express written permission from the copyright holder.
Copyright 2018 Gale, Cengage Learning. All rights reserved.

Article Details
Printer friendly Cite/link Email Feedback
Title Annotation:CASE REPORT
Author:ozsoy, omur Polat; Pamukcu, Hande
Publication:Turkish Journal of Orthodontics
Date:Jun 1, 2018
Previous Article:Cone Beam Computed Tomography in Orthodontics.
Next Article:Differential Benefit of Two Different Tooth-Borne Rapid Maxillary Expansion Appliances in Female Subjects.

Terms of use | Privacy policy | Copyright © 2021 Farlex, Inc. | Feedback | For webmasters |