Lingual dental braces -

What are they? How do they work? | Advantages & Disadvantages | Case selection - Who can have them? | Difficulties with wearing. | Brands- Incognito®, Harmony®, SureSmile®.

A picture of lingual dental braces on lower front teeth.

A lingual orthodontic appliance.

Lingual braces are one of the "invisible" treatment options that your orthodontist may have to offer.

For the most part, they look like conventional dental braces that have been mounted on the backside (reverse, lingual, tongue side) of your teeth. This hides them from view, making them difficult to see by others.

Brand names.

Some of the brands associated with this technique are: Incognito® and iBraces® (by 3M), SureSmile® L (by OraMetrix), and Harmony® (by American Orthodontics).

We've broken our discussion of this topic into the following sections:


Lingual dental braces -

"Inside" vs. "Outside" dental braces.

An animation showing the different positioning of lingual and conventional dental braces.

The location of the patient's appliances is reversed.

What are they?

Lingual braces are a method of orthodontic treatment where the brackets, wires and elastic bands used to realign your teeth are all mounted on their backside (tongue side). And due to this reverse positioning, they're sometimes called "inside" braces.

In comparison, the kind of braces you're probably most familiar with can be thought of as "outside" appliances, in the sense that all of their hardware is mounted on the side of the patient's teeth that shows.

Even though the location of the appliances used is reversed, lingual braces and its technique share many similarities with conventional ones in terms of the type of hardware and orthodontic principles involved.

Advantages

a) Their location makes them invisible.

One primary advantage of having lingual treatment lies in the fact that your braces are generally non-visible to others. If someone looks into your mouth they may catch a glimpse of your appliances (especially if you're wearing them on your lower teeth). But otherwise they're not easily detected.

So, if you feel that wearing conventional braces would simply be too embarrassing, this is one of the "invisible" orthodontic methods that you might consider (see box below).

Advantages over Invisalign®.

Another "invisible" braces option is wearing clear plastic removable tooth aligners like Invisalign®. But lingual braces are generally considered to be the less visible of the two. Here's why:

  • On close inspection, the aligners can sometimes be seen, or may give off a sheen that hints that they're being worn.
  • Treatment with removable aligners often requires the placement of buttons or attachments on the front side of your teeth. The more that are needed, the more noticeable it can be that you're having treatment.

Beyond these visibility issues, other really big advantages of using a lingual approach are:

  • It allows the dentist more control over tooth movements (it's on par with conventional braces).
  • And unlike when removable aligners are worn (or, more importantly, not worn), the issue of patient compliance is never a problem.

b) System sophistication / Precise, predictable outcome.

As we describe below, modern lingual braces systems are astoundingly sophisticated. They include optical impression taking, digital treatment planning, and the use of custom-made, patient-specific brackets and archwires. Conventional (front side) braces cases frequently/commonly involve none of these.

With this level of technology, combined with the advantage that bracket-and-archwire systems have in granting the dentist detailed control over tooth movements, lingual treatment can be expected to provide results that meet or exceed those of any other orthodontic technique.

c) A shorter treatment period may be required.

At least two studies (Saxe 2010, Sachdeva 2012) [page references] have reported that treatment involving SureSmile® (one of the most advanced lingual systems available) requires less time than conventional braces for case completion.

Saxe found a treatment time savings of 14.7 vs. 20 months. Sachdeva found a savings on the order of 15 months vs. 23.

Disadvantages

As disadvantages for this technique:

  • The biggest issue that lingual braces tend to pose is that they can be difficult to get used to and wear. (We discuss these matters at length below.)
  • Also, each individual office appointment you require during your treatment process will likely take longer than it would with front-side braces (just due to the more difficult to access location of your hardware). However, with some lingual systems fewer periodic appointments are needed.

However with the continued development of lingual systems, these points tend to become less and less of an issue.

Who can have lingual treatment?

The best (and really only) way to find out if lingual braces can be used in your situation is to have a consultation appointment with an orthodontist. In most cases, most adults and adolescents do make suitable candidates. But you'll simply have to find out for yourself.

An illustration showing how lingual brackets may interfere with the patient's bite.

Bite interference with a lingual bracket due to a deep vertical overbite.

a) "Deep bite" considerations.

One issue that's frequently discussed as a contraindication for having lingual braces is associated with the patient's "bite," and whether or not it allows enough room to accommodate the patient's braces.

The idea is that people whose teeth overlap extensively (they have a "deep vertical overbite") might place heavy forces on their brackets when they chew or close their teeth together. If so, they might damage or knock them off.

It's debatable how much of a problem this really tends to be, especially in light of the fact that today's custom-made lingual brackets have a profile (the height they stick up off the surface of a tooth) that's only about half of what was common just several years ago.

b) Quality of results.

It's true that in its infancy lingual braces was a difficult technique for dentists to practice (inferior bracket design, difficult bracket mounting protocol, poor bracket retention, difficult clinician access to the patient's appliances in their mouth), and as a result case outcome often suffered. But that all lies in the past.

At its current stage of development (improved bracket designs, custom-made brackets, simplified mounting methods, better overall bracket retention, optical impression taking, computer assisted treatment planning, the inclusion of CAD/CAM and robotic wire-bending technology), there's nothing inherently lacking about lingual technique.

The results it provides and the level of case outcome predictability it offers lies on par with conventional (outside) braces, if not better.


How difficult is it to get used to wearing lingual dental braces?

What type of problems or difficulties can you expect?

As a general rule, it's more difficult and takes longer to get used to wearing lingual braces than it does conventional (front side) ones. Here are some of the common problems that people encounter.

a) Tongue issues.

Your lingual braces will certainly be a curiosity to your tongue, in the sense that it won't be able to stay away from them. And of course as it performs its routine functions, it will find that your braces occupy some of the space it is used to having.

Of course, in a match between the soft tissues of your tongue and the harsh irregular surface of your braces, it will be your tongue that ultimately looses out. And that means you can expect it to be sore, even persistently so, especially during the first few weeks of getting your new braces. Beyond just feeling roughed up, you may also notice tongue redness or the formation of an outright sore.

Studies and statistics.
  • A study by Fritz (2002) determined that 65% of patients reported experiencing some degree of tongue impairment (this included irritation, injury and restricted functional space), making it the most common complication associated with wearing lingual braces.

    97% of patients classified their impairment as being "slight to moderate." With 82% stating that they had adapted to their initial difficulties within the first 1 to 3 weeks of wearing their appliances.

Other studies have reported more-intense and longer-lasting tongue issues.

  • A study by Sinclair (1986) found that all lingual patients reported some degree of tongue discomfort, which typically lasted for fewer than 14 days after the placement of their braces. But 18% experienced lesions and soreness for more than a month.
  • An evaluation of patients by Fillion (1997) found that 27% of patients categorized the level of tongue impairment associated with their lingual appliances as being severe. And 36% required an adaptation period longer than three weeks.

The differences in the findings of these studies probably has to do with the characteristics of the lingual braces system used. (See next section.)

Tongue issues tend to be less of an issue with modern lingual systems.

The current trend in lingual orthodontics is one where a patient's braces are now smoother, more rounded, lower profile appliances. And these characteristics make wearing a modern system less likely to cause tongue side effects.

Whereas with older, bulkier systems the patient's appliance might extend as much as 3.5 mm off the surface of their teeth (a little more than 1/8th of an inch), with newer bracket designs and modern methods of cementation (where a thinner layer of cement is used) this amount now tends to be more on the order of 1.5 mm (Slater 2011).

This smoother, flatter, sleeker profile (1/16th of an inch, about twice the thickness of a credit card) tends to create less of an obstacle for your tongue, thus aiding with comfort and adaptation issues.

Solutions for tongue irritation.

Over time your tongue should "toughen up" and adapt to your new braces, although as we discuss above it may take several weeks.

  • To help things along, rethink the way you create tongue-thrust and swallowing motions, and the level of aggressiveness you use.
  • A protocol where the placement of your braces is performed one arch at a time (separate appointments for upper and lower teeth) is generally accepted as one that tends to assist with patient comfort. (McMullin 2013)

Remedies for tongue soreness that may help:

  • Frequent use of warm saltwater rinses can help to speed up healing.
  • Over-the-counter products that contain an anesthetic like benzocaine (Orajel®, Ambesol®) can be used to temporarily numb your tongue so it's more comfortable.
  • As a protective measure, orthodontic wax can be placed over the sharp edges of your brackets and wires. (Get it from your dentist, or the dental section of your local store.)
  • Your dentist may make protective silicone "pads" for you that you wear over your braces that help to protect your tongue.

b) Speech issues.

You can expect, especially initially, that having lingual braces will affect the way you speak. This may be especially noticeable with "S" and "T" sounds.

Studies and statistics.
  • A study by Fritz (2002) determined that 24% of subjects with lingual braces experienced speech difficulties initially.

    97% of participants rated their treatment impairments (all types, including speech difficulties) to be "slight to moderate." With 82% reporting that their problems had resolved after an adaptation period of one to three weeks.

  • A study by Caniklioglu (2005) found that 23% of subjects were still having difficulties with their speech three months after initially having their lingual appliances placed.
  • Discussion in an article about lingual orthodontics by Slater (2011) references a 1997 survey that reported that 82% of patients felt that their ability to speak had returned to normal within one month of starting their treatment.

    The article points out however that this still leaves 18% of patients with some degree of speech impairment. And for some of these people their difficulty will persist until their treatment has been completed and their appliances finally removed.

    That contrasts the norm with conventional front-side braces where patients who do report some speech difficulties adapt within 30 days. (McMullin 2013)

The cause of speech problems.

It's easy enough to understand why lingual braces tend to affect your speech. When you speak your tongue needs to make contact with the backside of your upper front teeth, or upper side ones, to create certain sounds.

Since this is the exact same location where your braces have been cemented, an obstacle to normal function exists. Surprisingly, in most cases your tongue will be able to figure out a way to adapt to this added bulk and irritation, with your speech returning to normal/close to normal.

Modern lingual systems tend to affect speech less.

As discussed above with the issue of tongue discomfort, with modern, custom made lingual systems the trend is one where the contours of the patient's appliances are smoother, more rounded and have a lower profile (the amount they stick up off the surface of your teeth). And these characteristics help to minimize the degree to which they interfere with the tongue's motions and its ability to adapt to their presence.

Solutions for speech problems.

The remedy for problems with speaking is simply practice, and lots of it. Read a book or magazine out loud. Or when alone, say all of your thoughts out loud.

Over time, hopefully, your tongue should find ways to adapt. It might take just a few hours, or even several weeks. Even if you never fully adapt, your efforts should produce some degree of improvement, and accomplish it more rapidly.

c) Issues with eating

It's a simple fact, wearing lingual appliances will make eating more difficult. Some foods will tend to get trapped in your braces. Hard ones even have the potential to damage them. Bottom line, you'll experience a learning curve with eating as you figure things out.

Studies and statistics.
  • In an evaluation of patients wearing modern-design lingual appliances, Sanborn (2009) reported that eating, chewing and food collection each rated a functional impairment score of around 4 during the first three days after placement. (0 to 10 scale, with 10 being "as bad as you can imagine.")
  • After an eight week period of adaptation, this rating had only fallen to a level of around 2 for each of these events.
  • These scores were higher than those reported for all other lingual braces impairments, at respective points in time. (Other impairments included those associated with: talking, pronunciation, lack of functional space for the tongue, swallowing, the presence of oral lesions, teeth cleaning).

    While we don't know the significance of this comparison, it does suggest that food related difficulties do play an aggravating role in a patient's treatment experience.

Solutions for problems with eating.

In general, it's best to avoid crunchy, hard, sticky and chewy foods. Also, you'll tend to do better if you cut your food up into smaller pieces.

Typically troublesome foods: apples, raw vegetables (carrots, celery, radishes), nuts, hard rolls or pizza crust, toffee, bubble gum.

Foods that are easier to eat: rice, pasta, fish, cooked vegetables, soft bread.

d) Cleaning your teeth.

It's pretty easy to expect that wearing lingual braces will make it harder and more time consuming for you to brush and floss your teeth.

Studies and statistics.

In the same study referenced above (Sanborn 2009), lingual appliance patients scored difficulties associated with tooth cleaning around 4 on day one, 3 by day seven, and around 2 at eight weeks out. (A 0 to 10 scale was used with 10 being "as bad as you can imagine.")

Once can only assume that for everyone this issue remains a nuisance for them throughout their entire treatment period.

Teeth-cleaning tips.

Despite the difficulty involved, your goal always needs to be that of cleaning your teeth and braces after every meal and snack. Failure to do so places you at increased risk for tooth decay and gum complications.

  • Generally speaking, a smaller-headed toothbrush should tend to make cleaning easier.
  • Using an electric toothbrush can be beneficial too. If so, look for one that has a smaller-sized brush head option.
  • Other tools that can be useful are pipe cleaners, interdental bushes (Proxabrush®) and specialty dental flosses (Super Floss®).


How are lingual braces made and placed?

Today's systems are very sophisticated.

The fabrication and placement process used with the newest lingual systems is amazingly advanced.

Using the Incognito® lingual system as an example, digital treatment planning and case presentation, CAD/CAM manufacturing, 3D printing and robotic wire bending technology are all utilized in treating the patient. If the dentist has the needed equipment, optical impression taking can be incorporated into the process too.

  • The archwires used (the long, single wire that engages all upper or lower tooth brackets) are custom fabricated for each individual patient's case.

    Wire bending can be a difficult aspect of providing lingual orthodontics. Having pre-fabricated custom archwires to use aids the dentist in providing simplified, efficient and predictable treatment.

  • A patient's orthodontic brackets are custom made for each of their individual teeth.

    FYI: Custom brackets are a bit of a big deal. Since their shape is contoured to exactly fit the shape of your teeth, getting one back into place properly if it has come off is much easier for the dentist.

    Additionally, a precise bracket/tooth fit means that just a very thin layer of cement needs to be used. This helps to reduce the profile of the braces (how far they stick off the surface of your teeth).

  • All of an arch's (upper/lower) brackets are cemented at the same time, using a custom tray (jig) that positions each bracket precisely on its tooth.

In comparison, getting conventional (front side) braces, or being treated with an older-style lingual system, typically involves the use of standardized (stock) brackets and one-at-a-time placement.

The steps of getting lingual dental braces.

Picture of a detailed, high-accuracy dental impression.

The first step involves taking dental impressions.

A) Taking impressions of your teeth.

As a first step, your orthodontist will need to take a set of accurate and detailed impressions of your upper and lower teeth.

These might be conventional ones, taken using trays filled with impression putty (see picture). Or if your dentist has a scanner, they'll take digital impressions of your teeth and jaws optically.

Your impressions, along with a prescription from your dentist outlining how they want your case treated, are then sent to an orthodontic laboratory where your hardware (brackets and wires) will be made.

B) Fabricating your braces.

Once received, the orthodontic laboratory will make casts from the impressions that your dentist has sent.

A technician will then, per your orthodontist's prescription (instructions), create a "setup" of your case by modifying these casts. (A "setup" is a mockup of your teeth arranged in perfect alignment.)

Creating your treatment plan.

Once completed, the setup is then scanned into a computer and shared online with your dentist. They will review, revise as needed and ultimately approve the projected outcome of your case.

Picture of the design of a lingual orthodontic bracket made by a computer.

Custom brackets are computer designed for each tooth.

Creating your hardware.

The digitized information based on your doctor's approved treatment plan is then used to design and make your appliances.

Customized orthodontic brackets are created for each of your teeth using CAD/CAM technology. Robotic wire bending is used to create the series of archwires that will be used for your treatment.

The applicator tray.

Once fabricated, your set of brackets are embedded into upper and lower applicator trays. This custom-made stent (jig) will fit over your teeth and hold your brackets in precise position during the procedure used to bond them into place.

At this point, all of the your orthodontic hardware is returned to your dentist's office. The turn-around time needed for the fabrication process is usually just a couple of weeks.

C) Attaching your braces to your teeth.

An appointment will be made for you during which your orthodontist will attach your custom-made brackets to your teeth. The timing for this appointment is usually about four weeks after your impressions were initially taken.

Placing your brackets.

The cementation process is relatively straightforward. All of your brackets for each arch (upper/lower) are bonded simultaneously.

  • To start, your orthodontist will prepare the surface of your teeth so the bonding will adhere to them properly.
  • They'll then apply cement (the bonding) to each of the brackets and then press the applicator tray that holds them into place over your teeth.
  • The idea is that the applicator tray ensures that each individual bracket remains in precise alignment until its cement has cured.
Picture of a lingual orthodontic appliance.

Lingual braces mounted in place.

Once the cement has set, your orthodontist will break away the applicator tray. Your brackets will remain in place on your teeth. Any excess bonding will be scraped off or trimmed away.

Now that your brackets have been secured, the first of the pre-bent arch wires that the laboratory has prepared can be installed. Your active treatment has now begun.

Takeaways from this section.

Actually, the process of placing all of the brackets simultaneously is a bit of a concern to your orthodontist.

Via the use of the applicator tray, they attach all of the brackets simultaneously, without having the ability to directly observe that each is being bonded properly.

A major concern would be that not enough cement has been used with a bracket and as a result some amount of unfilled space exists between it and the tooth underneath. If that's the case, the bracket might ultimately debond (come off). Also, any dental plaque accumulation in the void could cause a cavity.

On a practical level, this issue doesn't pose all that much risk. But you can be assured that your dentist will inspect each cemented bracket with this possibility in mind.

As an alternative, lingual brackets can be attached their teeth one tooth at a time (which is the case when stock brackets are used). The trade-off is that this process is tedious and time consuming, which is an inconvenience for both the dentist and the patient.

Non-customized lingual appliances.

Despite the availability of sophisticated lingual systems like we've just described, an orthodontist may choose to treat some cases with non-custom appliances. This means:

  • Using stock (pre-made, off-the-shelf) orthodontic brackets.
  • The dentist will perform the needed archwire bending on their own.

Using this approach is more common with comparatively simpler cases. And when used, offers a cost benefit for the dentist, which is hopefully passed on to the patient too.

Disadvantages.

For the patient, the use of stock brackets poses some disadvantages.

  • Since the bracket doesn't have a shape that exactly mirrors the surface of the tooth it will be bonded onto, a thicker layer of cement will need to be used to compensate.

    That means that the person's appliance will have a higher profile (stick up off the surface of their teeth further) than if custom-made brackets were used.

  • A thicker layer of cement also makes the integrity of the bond itself less predictable.

(McMullin 2013)


Why don't all orthodontist place lingual braces?

Not every dentist has an interest in providing treatment using lingual dental braces. (Especially here in the USA. In other parts of the world, the use of this treatment approach is much more common.) Here are some reasons why:

a) Providing treatment is more involved.

As a technique, preforming lingual treatment adds some difficulties for the treating orthodontist that conventional (outside) braces don't pose.

  • The patient's orthodontic brackets are attached to the backside of their teeth where visibility and access is more difficult.
  • The shape of the archwire that runs through each bracket may not have a smooth continuous curve like that used with front-side (straight archwire) braces. If not, the patient's treatment will require making fairly complex bends (a mushroom-shaped archwire).
  • Factors like the level at which the brackets are bonded onto their teeth, the nature of how close together the brackets are (interbracket distance) or the sharpness of the curve of the wire used (small arch perimeter) and it's degree of flexibility all introduce new variables that contribute to making the use of this technique fairly different from conventional (outside) braces.

All of the above points mean that there will be a definite learning curve for any orthodontist switching from just providing conventional front-side to including lingual therapy as they adapt to its different set of imposed conditions. And many may not be interested in undertaking this challenge.

But we should also point out that there's no question that the recent developments and advancements in this technique (described above) have greatly simplified the way treatment is currently performed over that of previous decades. Thus making it more acceptable to more and more providers.

b) Competing "invisible" methods.

Beyond just lingual braces there are other minimally-obvious orthodontic systems that an orthodontist can offer.

  • This includes the use of clear and tooth-colored ceramic brackets with conventional front-side braces cases. And while there are new issues to be learned when these kinds of brackets are used, they are minimal.
  • Clear plastic removable aligner systems, like Invisalign® (see link above), offer another aesthetic alternative. If the dentist is new to this type of system, some degree of learning/course work is required. But generally speaking, being able to provide this type of treatment (level of knowledge and skill required) is generally less than with lingual braces.

c) Additional training is needed.

Companies that make some of the more sophisticated lingual braces systems require that the treating orthodontist must take specialized training from them. But you shouldn't necessarily be too impressed with this fact.

The time involved in completing this needed coursework may be as little as a day. However, for those dentists who are interested, certainly more advanced courses are available.


What's the fee for lingual braces?

The only issue we haven't discussed on this page is lingual braces costs. Use that link for fee estimates for this procedure, different ways that can be used to minimize your overall expenses, and a comparison to the costs involved using other orthodontic methods.


A brief history of lingual braces.

The idea of providing lingual orthodontic treatment got its start at around the same time (the mid 1970's) in two different countries.

  • Professor Kinja Fujita (Japan) is usually credited with being the original pioneer of modern lingual treatment.

    A primary motivation for his efforts was to develop a method of providing orthodontic care for patients who practiced martial arts and therefore needed a treatment approach that better protected their lips and cheeks from injury.

  • In the USA, Dr. Craven Kurz of Beverly Hills, California independently developed his own system. His main motivation was simply to find a way to provide treatment for patients in a less noticeable way.

(Echarri 2006, McMullin 2013)

Unfortunately, in its early forms lingual braces as a technique was generally difficult for dentists to practice (inferior bracket design, mounting protocol and retention) and frequently resulted in a poor outcome for the patient. And as a result, interest in this technique subsided into the 1990's.

Since then, the technological advances outlined above in bracket design & placement and case treatment planning along with the inclusion of CAD/CAM and robotic wire-bending technology have lead to a resurgence in the use of this technique, as well as patient demand. (McMullin 2013)

 

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