Tribuna Books Ripano 3 (Eng) by Ripano S.A.

TRIBUNA BOOKS RIPANO

Nº 3 - 2014

Lingual Orthodontic Journal

Contents •

Multi-slotted lingual bracket: Tandem arch wire technique. Ryoon-Ki Hong

•

Comparison of perception experienced by patients treated with conventional and lingual orthodontics. Carla Maria Melleiro Gimenez, Marcelo Marigo, Rita de Cássia Baratela Thurler, Luis Fernando Eto

•

Fabrication of ideal lingual arch wire template with Accurate Bracket Positioner. Pablo Echarri, Martín Pedernera, Miguel A. Pérez-Campoy

Editor in Chief Pablo Echarri

Editorial Committee

Silvia Geron Ryoon-Ki Hong Hee-Moon Kyung Jean-François Leclerc Marcelo Marigó Martín Pedernera Miguel A. Pérez-Campoy Rafi Romano Giusseppe Scuzzo Kyoto Takemoto

Editorial assistant and translator Nataša Pešić

Publishing and advertising

Ripano S.A. Ronda del Caballero de la Mancha, 135 28034 - Madrid, Spain Tel.: (+34) 913 721 377 Fax: (+34) 913 720 391 e-mail: ripano@ripano.es www.ripano.eu Nº 3 - 2014 ISSN: 2340-9940 Official publication:

The views and opinions expressed in this publication are those of the authors and do not necessarily reflect the official policy or position of Ripano Editorial. No part of this publication may be reproduced, stored or transmitted in any form or by any means, electronic or mechanical, without permission in writing from the publisher.

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Lingual Orthodontic Journal

Editorial I would like to start this editorial greeting of the latest issue of Tribuna Books Ripano Lingual Orthodontic Journal by inviting all its readers to the 6th WSLO Congress which will take place in Seoul from July 3rd to 5th 2015. Professor Ryoon-Ki Hong has been preparing this congress with the main topic Evolution and revolution in Lingual Orthodontics, with the participation of the most important lecturers from all over the world, in modern facilities of Coex Grand Ballroom. On the other hand, Seoul is a marvelous city to visit, so I warmly recommend to book some extra days so you can enjoy it. This new issue brings us a very interesting article written by Prof. Hong, then an article written by Dr. Melleiro, Dr. Marigo, Dr. Baratela Thurler and Dr. Eto, as well as the article by Dr. Echarri, Dr. Pedernera and Dr. PĂŠrez-Campoy. I hope you enjoy them. Again, I would like to repeat my invitation for all of you to send us your articles for this journal, and to thank you congratulations and comments on our last issue. Warm regards,

Pablo Echarri

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Multi-slotted lingual bracket: Tandem arch wire technique Author: Ryoon-Ki Hong, DDS, PhD

Abstract Since the advent of lingual brackets by Fujita in 1979, many lingual brackets have been developed. Most available lingual brackets are single-slotted, which have either lingually opening or occlusally opening slots. Lingually opening slots have advantages for some types of tooth movement and disadvantages for other types of tooth movement. It is same for other brackets with single occlusally opening slot. Because multi-slotted lingual brackets such as Fujita lingual bracket and Anboini have both lingually opening and occlusally opening slots, they make use of tandem arch wire techniques, in which two arch wires are engaged simultaneously in both occlusally and lingually opening slots. These advanced techniques not only prevent undesirable reaction forces from becoming manifest, but also make treatment simple and efficient for both the clinician and patient. Key Words: multi-slotted lingual bracket, lingually opening slot, occlusally opening slot, Tandem Arch Wire Technique.

Introduction With the invention of the resin bonding system, lingual brackets were first developed by Fujita in 1979.1,2 The occlusally opening slot was installed on the Fujita bracket in order to facilitate insertion and removal of the orthodontic wire. Soon after, Kurz et al introduced their lingual brackets in 1982, which have an 0.018×0.025-inch lingually opening slot like labial bracket.3 Creekmore published his bracket designs and related clinical findings in 1989.4 The foundation of the design is the opening of the arch wire slots to the occlusal aspect rather than to the lingual aspect. The slot size of the bracket is 0.016-inch horizontally and 0.022-inch vertically. Many lingual brackets have been developed thereafter. Scuzzo and Takemoto introduced STb, which has a lingually opening 0.018×0.025-inch slot.5 Selfligating lingual brackets such as Clippy-L and Evolution were introduced, which have lingually opening 0.018×0.025-inch slot and occlusally opening 0.018×0.025-inch slot, respectively. Due to recent developments in CAD/CAM software, individually customized lingual brackets such as Incognito6 and Harmony have been developed. Anterior Incognito bracket has an occlusally opening 0.025×0.018-inch slot and posterior Incognito bracket has a lingually opening 0.025×0.018-inch slot. Harmony bracket has a lingually opening slot in the form of self-ligation, in which slot size can be made as we request.

More recently, Scuzzo and Takemoto introduced selfligating STb, which has an occlusally opening slot.7 The size of the occlusally opening slot is 0.018×0.018inch square, not rectangular. They suggested that the square slot is more effective than rectangular slot in correcting rotation. Furthermore, with occlusally opening slot bracket, the arch wire is prevented from disengaging during retraction, resulting in minimal loss of torque and better control. Most available lingual brackets are single-slotted and each bracket system has its unique design. Some brackets such as Kurz, STb, Clippy-L and Harmony have a lingually opening slot and other brackets such as Evolution and self-ligating STb have an occlusally opening slot. Incognito has both occlusally opening and lingually opening slots, which are installed in anterior and posterior brackets, respectively. Lingually opening slots have advantages for some types of tooth movement and disadvantages for other types of tooth movement.8 It is same for other brackets with single occlusally opening slot. Because multi-slotted lingual brackets such as Fujita lingual bracket and Anboini have both lingually opening and occlusally opening slots, they make use of tandem arch wire technique, in which two arch wires are engaged simultaneously in both occlusally and lingually opening slots. In this article, applications of tandem arch wire techniques will be discussed for alignment, leveling, space closure, and finishing. Occlusally opening slot will be called vertical slot and lingually opening slot, called horizontal slot.

Lingual Orthodontic Journal

Fig. 1. An example of the tandem arch wire technique used during alignment.For space regaining, a 0.016-inch stainless steel mushroom arch wire (016 SS-MAW) was engaged in the maxillary horizontal slots to begin partial retraction of the canines and lateral incisors with elastic thread (ET). After partial retraction, a 0.012-inch nickel titanium segmental arch wire (012 NT-SEG) was engaged in the vertical slots from canine to canine to correct the protruded central incisors. With this tandem wire system, active alignment of the protruded maxillary central incisors was achieved simply by means of the light flexible 0.012-inch nickel titanium segment, and any undesirable reaction forces that would otherwise have been generated (specifically, anterior flaring) were contained by the rigid 0.016-inch stainless steel mushroom arch wire. A. During partial retraction of the canines. B. After gaining sufficient space to align the protruded maxillary central incisors. C. After correction of the protruded maxillary central incisors.

Tandem Arch wire Technique during Alignment Because inter-bracket distance is relatively smaller from the lingual aspect, as contrasted with the labial, it may not be possible to bond all brackets to their most appropriate positions even in cases of mild crowding. In these cases, neighboring teeth may sometimes be retracted to regain space prior to bonding of the more crowded teeth. If the tandem arch wire technique is used at this point, crowding can be solved in a more effective and simpler way. Anchorage complications may also become nullified. Figure 1 shows a case treated with the tandem arch wire technique for the correction of protruded maxillary central incisors. The mushroom arch wire was engaged in the horizontal slots to partially retract the canines and lateral incisors. After the space was regained, a light segmental arch wire was engaged in the vertical slots of the six anterior teeth, without re-

moving the existing mushroom arch wire within the horizontal slots. With this tandem arch wire method (specifically with the main, stronger, mushroom arch wire engaged in the horizontal slots and the more flexible segmental arch wire simultaneously ligated into the vertical slots), the protruded maxillary central incisors were simply and effectively corrected without side effects. It is important to note that a single arch wire might likely have caused flaring of the upper anterior segment as a whole, with attendant strains on posterior anchorage and increased treatment time.

Tandem Arch wire Technique during Leveling In lingual orthodontic treatment, unlike with labial treatment, anterior intrusive forces pass through or close to the collective center of resistance of the anterior teeth; thus, anterior intrusion tends to be

Dental Tribuna Books executed more simply and favorably.2 Various techniques for intrusion of mandibular anterior teeth that exploit these advantages have been introduced.9,10 Among these techniques, modified intrusion mechanics10 derived from Burstone’s segmented arch technique can be applied in a straightforward manner to lingual orthodontic treatment, thanks to the availability of the extra outer horizontal slot within each mandibular first molar bracket. The patient in Figure 2 presented with upper peg lateral incisors and spacing. After the spaces were consolidated, resin crown build-ups were planned for the lateral incisors. Furthermore, although the overbite was not excessive, interferences between the maxillary anterior lingual brackets and mandi-

bular anterior teeth were anticipated. Orthodontic brackets were therefore bonded first onto the mandibular teeth, and later onto the maxillary teeth only after mandibular anterior intrusion had been established. For intrusion of the six mandibular anterior teeth, 0.018×0.018-inch stainless steel segmental arch wires were engaged in the vertical slots of the anterior and posterior teeth. 0.017×0.025-inch titaniummolybdenum alloy (TMA) bilateral intrusive springs were engaged simultaneously in the inner horizontal slots of the mandibular first molar brackets, and activated by connection to the anterior segmental arch wire between the lateral incisors and canines (Fig. 2C). By using the tandem arch wire technique (ie.

Fig. 2. An example of the tandem arch wire technique used during leveling. To intrude the six mandibular anterior teeth, 0.016×0.016-inch stainless steel segmental arch wires (016×016 SS-SEG) were engaged in the vertical slots of the anterior and posterior teeth bilaterally, and 0.017×0.025-inch TMA intrusion springs (017×025 TMA-IS) were engaged in the inner horizontal slots of the mandibular first molar brackets, with the active spring ends hooked between the lateral incisors and canines of the anterior segmental arch wire. By using this variation of the tandem arch wire technique (i.e. segmental arch wires in the anterior vertical slots and intrusive springs in the posterior horizontal slots simultaneously), the six mandibular anterior teeth were simply and effectively intruded without side effects. A. Pre-treatment views. B. After intrusion of the six mandibular anterior teeth. C. To intrude the six mandibular anterior teeth, 0.016×0.016-inch segmental arch wires (016×016 SS-SEG) were engaged in the vertical slots of the anterior and posterior teeth respectively, and 0.017×0.025-inch TMA intrusion springs (017×025 TMA-IS) were engaged in the inner horizontal slots of the mandibular first molar brackets, with the active ends hooked to the anterior segmental arch wire between the lateral incisors and canines.

Dental Tribuna Books here with segmental arch wires in the vertical slots and intrusive springs in the inner horizontal slots simultaneously), the six mandibular anterior teeth were simply and effectively intruded without side effects.

The Tandem Arch wire Technique for Space Closure Lingual patients make consistently strong demands that a high quality of esthetic appearance will be maintained throughout their treatment. This prerequisite means that, in addition to the use of invisible braces, spaces between lateral incisors and canines at any time during treatment must be avoided. Therefore, where necessary owing to premolar extractions, the anterior segment is retracted en masse in lingual orthodontic treatment. If the arch wire is engaged in horizontal slots for anterior retraction, the arch wire may slip from the slots and anterior torque control or rotation control can end in fail. On the contrary, if the retraction arch wire is engaged in vertical slots, canines are tipped into extraction space and a vertical bowing side effect is produced. To prevent these side effects during anterior retraction, retraction arch wire is engaged in the horizontal slot and simultaneously 0.018×0.018-inch stainless steel segmental arch wire is engaged in the vertical slot of 6 anterior teeth (Fig. 3). This tandem arch wire technique is routinely applied during anterior retraction. With this tandem technique, anterior torque, rotation, and tipping are easily controlled during retraction.11

The Tandem Arch wire Technique for Final Detailing Lingual brackets must be narrower than corresponding labial brackets. As a result, it is difficult to achieve angulation control. To control the mesiodistal angulation of a tooth, it is recommended to insert an uprighting spring in the accessory slot because the angulation of teeth is not controlled effectively with narrow vertical or horizontal slots. Uprighting springs can be used for angulation control of single or multiple teeth (Figs 4 and 5). The unilateral uprighting spring is used for angulation control of single tooth. It can be inserted either occlusally or gingivally, depending on the direction of angulation correction. Similarly, multiple unilateral uprighting springs can be used simultaneously for angulation control of multiple teeth. For angulation control, the uprighting spring is simply made and inserted in the

Fig. 3. The tandem arch wire technique used during space closure. For en masse retraction, an 0.016×0.022-inch stainless steel closing straight arch wire (016×022 SS-CSA) was engaged in the upper horizontal slots, and an 0.018×0.018inch stainless steel segmental arch wire (018×018 SS-SEG) was placed into the vertical slots of the anterior teeth. By using the tandem arch wire technique in this way, space closure via sliding mechanics can be carried out effectively and without vertical bowing side effects at the extraction sites.

accessory slot without removing the existing arch wire and making a new arch wire.

Conclusion Now, lingual orthodontics becomes “must know” field in orthodontic treatment. However, it is not easy to treat malocclusion with lingual bracket because lingually-applied orthodontic forces produce different tooth movement from labialy-applied forces. Narrow width of lingual bracket is also one of the important reasons why lingual orthodontic treatment is difficult. Narrow lingual brackets with single horizontal or vertical slot have limits to achieve desirable results. Using tandem arch wire techniques, multislotted lingual bracket overcomes the disadvantages of narrow lingual brackets in lingual orthodontics. These advanced techniques not only prevent undesirable reaction forces from becoming manifest, but also make treatment simple and efficient for both the clinician and patient.

References 1. Fujita K. New orthodontic treatment with lingual bracket mushroom arch wire appliance. Am J Orthod 1979;76:657-75.

Lingual Orthodontic Journal

Fig. 4. An example of the tandem arch wire technique used for angulation control of single tooth during final detailing. Distal root movement of mandibular right central incisor (arrow) was performed with a unilateral uprighting spring (US), which was inserted occlusally. By simple engagement of a unilateral uprighting spring, proper root axis was obtained without removal of the existing mushroom arch wire. A and C. Intraoral photo and orthopantomogram before angulation correction of mandibular right central incisor. B and D. Intraoral photo and orthopantomogram after angulation correction of mandibular right central incisor. E. A unilateral uprighting spring (US) in the accessory slot of the mandibular right central incisor, hooked to the arch wire between the mandibular left lateral incisor and canine.

2. Fujita K. Multilingual-bracket and mushroom arch wire technique. A clinical report. Am J Orthod Dentofac Orthop 1982;82:120-40. 3. Alexander CM, Alexander RG, Gorman JC, Hilgers JJ, Kurz C, Scholz RP, and Smith JR. Lingual orthodontics : a status report. J Clin Orthod 1982;16:255-63. 4. Creekmore T. Lingual orthodontics-its renaissance. Am J Orthod Dentofac Orthop 1989;96:120-37. 5. Scuzzo G, Takemoto K, Takemoto Y, Takemoto A, Lom-

bardo L. A new lingual straight-wire technique. J. Clin. Orthod 2010;44:114-123. 6. Wiechmann D, Rummel V, Thalheim A, Simon J-S, Wiechmann L. Customized brackets and archwires for lingual orthodontic treatment. Am J Orthod Dentofacial Orthop 2003;124:593-599. 7. Takemoto K, Scuzzo G, Takemoto Y, Scuzzo G, Lombardo L. A new self-ligating lingual bracket with square slots. J Clin Orthod 2011; 45:682-90.

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Fig. 5. An example of the tandem arch wire technique used for angulation control of multiple teeth during final detailing. Mesial root movement of upper right and left canines (arrow) was performed with two unilateral uprighting springs (US), which were inserted gingivally. A and B. Intraoral photo before angulation correction of upper right and left canines. C and D. Intraoral photo after angulation correction of upper right and left canines. E and F. Two unilateral springs (US) inserted in the accessory slots of the maxillary right and left canine brackets, hooked to the arch wire between the maxillary right and left central incisors.

8. Hong RK, Sohn HW. Update on the Fujita lingual bracket. J Clin Orthod 1999;33:136-142. 9. Hong RK, Hong HP, Koh HS. Effect of reverse curve mushroom archwire on lower incisors in adult patients. Angle Orthod 2002;71:425-432.

10. Hong RK, Kim TG, Lim SM, Lee CH. Modified intrusive mechanics in lingual segmented-arch technique. J Clin Orthod 2005;39:489-495. 11. Lim SM, Hong RK. The tandem archwire technique in lingual orthodontics. J Clin Orthod 2013;47:232- 40.

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Comparison of perception experienced by patients treated with conventional and lingual orthodontics Authors: Carla Maria Melleiro Gimenez Marcelo Marigo Rita de CĂĄssia Baratela Thurler Luis Fernando Eto

Abstract Objetives: To compare the perception experienced by patients treated with labial and with lingual orthodontics. Methods: Seventy adult patients (both genders), 35 treated with labial and 35 with lingual technique, answered a questionnaire regarding main reasons for adhesion; aesthetical and functional importance; contribution of the treatment, its advantages, satisfaction and potential indications. All of them had the brackets bonded for 6 months or more. Statistical analysis was Q2 Test (significance level 5%). Results: Findings indicated significant influence by treatment type for: reasons, contribution and improvements of the treatment. Functional importance and high satisfaction level were more related to lingual technique. The disadvantages reported by patients were: high cost for lingual technique and discomfort for labial technique. Conclusions: Some paradigms regarding lingual treatment are not true. The aesthetics and fast results were important factors for both techniques and the lingual patients showed more treatment valorization and satisfaction. Key Words: Lingual Orthodontics, Orthodontics, Aesthetics, Treatment Perception.

Introduction Nowadays the adult patients are more and more interested in the orthodontic treatments, representing considerable percentage of the market. However, most of the time a negative reaction is noted in relation to the conventional appliances, because these patients have an aesthetic preference and do not accept to show the braces during treatment time. Caniklioglu C, OztĂźrk Y, 2005. In general, the adults are motivated due to the possibility of improving their smile and facial aesthetics. Therefore, the orthodontic appliance cannot interfere with their self-image, being an inconvenient for the appearance and quality of life. Wu AK, McGrath C, Wong RW, Wiechmann D, Rabie AB, 2010. In this context, the lingual orthodontics technique presents a viable option, in a way to keep the aesthetic and biomechanical efficiency. The aesthetics is perfect because braces are bonded to the inner sur-

face of the teeth where nobody can see them. In this way, the orthodontic treatment is carried out with discretion and in secret. On the other hand, the biomechanics takes the advantage of the proximity of the brackets to the resistance center, providing controlled and easier teeth displacement. (Miyawaki S, Yasuhara M, Koh Y, 1999; Brosh T, Strouthou S, Sarne O, 2005; Wu AK, McGrath C, Wong RW, Wiechmann D, Rabie AB, 2010.). There are many questions and myths regarding lingual orthodontics, especially in relation to the patientâ&#x20AC;&#x2122;s adaptation, comfort and satisfaction level. In this context, the aim of this study was to compare the perception experienced by patients treated with lingual and conventional appliances.

Methods The sample was randomly selected, counting with 70 adult patients (both genders) from two private offices, being organized in two groups of 35 patients according to braces type: lingual and conventional

Lingual Orthodontic Journal appliances. These patients had conventional or lingual brackets bonded for a period of 6 months or more. A questionnaire was given to both groups (conventional and lingual braces), regarding the main reasons for choosing the specific orthodontic treatment adhesion; aesthetical priority; functional importance; treatment contribution, advantages and disadvantages, satisfaction, how they knew about treatment option and potential indications. The patients did not sign the questionnaire and they answered it in secret, in order to keep the real impression about the treatment, without any influence by orthodontists or staff. The chosen statistical analysis for data evaluation was Quiquadrado (Q2), with significance level at 5%.

Statistical Planning The fundamental objective of the conducted survey was to answer the question: will the answers to the options given item be influenced by the types of braces? As a consequence of this objective, the hypothesis to be tested statistically was that the answers to the options given item would not influenced by the types of braces or they would not depend on devices type. This hypothesis was put to the test from the Chi-square statistic (Q2) being the decision rule to establish its significance or was not set from p = P (Q2> Qo2) - the statistical probability that Q2 is larger than its value observed (Qo2) in the data sample in the following manner: if p was equal to or smaller than 0.05, the tested hypothesis was significant or rejected, and otherwise, if p is greater than 0.05, then the tested hypothesis was not significant or not rejected.

Table 1. Frequency of responses regarding the chief complaint according to the appliance type. P-value.

Main Compliance

Conventional Appliance

Lingual Appliance

Total

p Value

Aesthetics

39.2

60.8

100.0

Orofacial Pain

62.5

37.5

100.0

Masticatory Dysfunction

100.0

0.0

100.0

Social Pressure

100.0

0.0

100.0

Phonetic Dysfunction

50.0

100.0

Respiratory Dysfunction

75.0

25.0

100.0

Total

51.3

48.7

100.0

0.026 s

s = significant value.

Results In Table 1, it was found that the value of p = 0.026 was significant, which indicated that the responses for the item “Which is the chief complaint that prompted you to search for orthodontic treatment?” were linked to the types of conventional or lingual

orthodontic treatments. In fact, if we observe the table 1, we can see: 60.8% of all the “aesthetic option” answers for this item were related to the use of lingual braces and 39.2% of them were related to the conventional device. The rest of the options for this item, except for “Phonetic Dysfunction”, had the higher percentage for conventional braces.

Dental Tribuna Books Table 2. Frequency of responses regarding the aesthetics importance according to the appliance type. P-value.

Aesthetics Importance

Conventional Appliance

Lingual Appliance

Total

p Value

Priority

44.4

55.6

100.0

Very Important

51.7

48.3

100.0

Important

50.0

100.0

Not so Important

Dispensable

Total

50.7

100.0

49.3

0.881 n

n = no significant value. Table 3. Frequency of responses regarding the adequacy of masticatory system according to the appliance type. P-value.

Masticatory System Adequacy

Conventional Appliance

Lingual Appliance

Total

p-value

Priority

45.2

54.8

100.0

Very Important

50.0

100.0

Important

100.0

0.0

100.0

Not so Important

100.0

0.0

100.0

Dispensable

Total

50.0

0.184 n

100.0

n = no significant value.

In table 2, it was found that the value of p = 0.881 was not significant, which indicated that the answers for the item “Aesthetics for you is:” were not linked to the types of treatments, so the answers attributed to particular option do not depend on the type of braces. In table 3, it was found that the value of p = 0.184 was not significant, which indicated that the answers for the item “Proper functionality of the masticatory system is:” were not linked to the types of treatments, so the given answers do not depend on the type of braces.

In table 4 it was found that the value of p = 0.007 was significant, which indicated that the responses for the item “Orthodontic treatment helped you to improve:” were linked to the types of treatments. In fact, looking at the table we can see: 1. The highest percentage of answers to the option “Aesthetics” (62.5%) for this item were related to the use of lingual braces, and the lowest, 37.5%, were related to the use of conventional appliances. 2. In the rest of the options for this item, higher percentage of answers was related to the use of conventional braces

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Dental Tribuna Books Table 4. Frequency of responses regarding the improvements by orthodontic treatment, according to the appliance type. P value.

Improvements

Conventional Appliance

Lingual Appliance

Total

p Value

Aesthetics

37.5

62.5

100.0

Orofacial Pain

70.0

30.0

100.0

Masticatory Dysfunction

90.0

10.0

100.0

Social Pressure

100.0

0.0

100.0

Phonetic Dysfunction

66.7

33.3

100.0

Respiratory Dysfunction

100.0

0.0

100.0

Total

53.9

46.1

100.0

0.007 s

s = significant value. Table 5. Frequency of responses regarding the best advantage of orthodontic treatment, according to the appliance type. P Value.

Best Advantage over

Lingual Appliance

Total

p-Value

Aesthetics

51.8

48.2

100.0

Fast Results

44.4

55.6

100.0

Reduced Treatment Time

100.0

Speech Difficulties

100.0

Bracket debonding

Discomfort

Hygiene

Professional Difficulties

High Costs

Masticatory Dysfunction

Total

100.0

n = no significant value.

Conventional Appliance

48.6

51.3

0.178 n

Lingual Orthodontic Journal Table 6. Frequency of responses regarding the satisfaction level reached by orthodontic treatment according to the appliance type. P value.

Satisfaction Level

Conventional Orthodontics

Lingual Orthodontics

Total

p-Value

Very Satisfied

0.0

100.0

Satisfied

53.8

46.2

100.0

Not so Satisfied

100.0

0.0

100.0

Unsatisfied

75.0

25.0

100.0

Total

51.4

48.6

100.0

0.001 s

s = significant value. Table 7. Frequency of responses regarding the potential indication of orthodontic treatment according to appliances type. P Value.

Indication

Conventional Appliance

Lingual Appliance

Total

p-Value

Yes

50.7

49.3

100.0

0.0

100.0

Total

50.0

100.0

0.314 n

n = no significant value.

In table 5, it was found that the value of p = 0.178 was not significant, which indicated that the answers for the item “For you, which is the greatest advantage resulting from an orthodontic treatment?” were not related to the types of orthodontic treatment, therefore, the answers given to certain option did not depend on the type of braces. In table 6, it was found that the value of p = 0.001 was significant, which indicated that the responses for the item “What is a degree of your satisfaction with the orthodontic treatment?’ were linked to the types of treatment. In fact: • All the answers “very satisfied” were related to the use of lingual technique; • All the answers “not so satisfied” were related to the use of conventional braces and the answer “unsatisfied” had higher percentage of responses for conventional appliances.

• The answer “satisfied” was attributed to both conventional and lingual appliances, and they were statistically equal. In table 7, we obtained p = 0.314 which was not significant because it was greater than 0.05. Thus there was evidence sampling not to reject the hypothesis that the type of orthodontic appliance has induced or not a positive indication.. In table 8, it was found that the value of p = 0.086 was not significant, which indicated that the answers for the item “How did you hear about the techniques of conventional and lingual orthodontics?” were not linked to the types of orthodontic treatments, so responses attributed to particular option did not depend on the type of braces. In Table 9 it was found that the value of p = 0.004 was significant, which indicated that the answers related to the item “Disadvantages resulting from the

Dental Tribuna Books Table 8. Frequency of responses regarding the orthodontic treatment information according to the appliance type. P Value. Conventional Appliance

Information by

Lingual Appliance

Total

p-Value

Dentists

58.3

41.7

100.0

Orthodontists

50.0

100.0

Other Health Professionals

83.3

16.7

100.0

Marketing

18.2

81.8

100.0

Internet

Friends

41.2

58.8

100.0

Others

71.4

28.6

100.0

Total

50.7

49.3

100.0

0.086 n

n = no significant value.

Table 9. Frequency of responses about disadvantages according to the appliance type. P Value.

Disadvantage

Conventional Appliance N

Total

p Value

Aesthetics

Faster Results

Reduced Time

Speech Difficulties

9.1

90.9

100.0

Brackets debonding

0.0

100.0

Discomfort

60.0

40.0

100.0

Hygiene

72.7

27.3

100.0

Professional Difficulties

0.0

100.0

High cost

20.0

80.0

100.0

Masticatory Difficulties

33.3

66.7

100.0

Total

100.0

s = significant value.

Lingual Appliance

0.004 s

Lingual Orthodontic Journal orthodontic technique”, were linked to the types of treatments. In fact, “speech difficulties”, “high cost” and “masticatory difficulties” were reported as the greatest disadvantage for lingual treatment, while discomfort was related to the use of conventional braces as the biggest disadvantage, as well as hygiene.

Discussion Even with a positive expectations regarding lingual treatment, our results (tables 1-9) surprise us due to the evidence that it is a viable option for orthodontic treatment which brings an aesthetic solution and provides excellent results with a high level of satisfaction and good potential indications for new patients. The aesthetics was the chief compliant for both techniques (table 1) and it was reported as priority, very important or important for all patients (table 2) independently on the appliance choice. The aesthetics improvement reached by the treatment was reported more times for lingual orthodontics (table 4) and it was reported as the best advantage (table 5) of the orthodontic treatment, although both techniques presented almost equal results in providing it. The literature confirms our findings showing that more and more patients do not accept an unesthetic appliance which can interfere with their self image (Caniklioglu C, Oztürk Y, 2005.; Wu AK, McGrath C, Wong RW, Wiechmann D, Rabie AB, 2010). The level of comfort was reported when the questionnaire asked about masticatory adequacy (table 3) and about improvements reached with the treatment (table 4). About comfort, Wiechmann et al. (2008) showed that the more maxillary or mandibular retrusion, the more discomfort probability exists with lingual orthodontics technique. In addition, Stam; Hohoff; Ehmer, (2005) confirm that more comfort related to Incognito was reported in comparison with 7th generation braces, due to the size and profile of the analyzed brackets. Following the same investigation topic, Hohoff; Stam; Ehmer, (2004) reported positive adaptation of lingual orthodontics patients, with some differences related to lingual bracket positioning, tongue space deficiency (related to the bracket size and profile) which can provoke smaller lesions like aftae. The importance and necessity to provide information for patients, improving and facilitating the adaptation process has been evidenced. In our work, a high level of adaptation has been recorded in tables 3, 4, 5, 6, 7, 9.

There is strong evidence that comfort increases with adaptation as the time passes. This is clinically evidenced and the literature also supports these findings (Hohoff et al. 2003). Table 9, which evidences the disadvantages, shows a big surprise: the main disadvantage reported by patients treated by lingual orthodontics was the high cost; while the main disadvantage reported by patients treated by conventional orthodontics was discomfort. The speech interference in the first period and trough adaptation time is an important disadvantage reported by lingual orthodontics patients. Table 9 as well as Hohoff et al. 2003, show the speech difference as well as a certain level of discomfort as important disadvantages. Having said that, it is also important to remember that the smaller lingual braces are, the smaller speech deficiency is reported. As far as the frequency is concerned, the initial discomfort related to lingual orthodontics is reported by 57% to 76% of patients (tongue pain, hygiene, T/S pronunciation, fibrous food), which is improved within the short period of time in 20-44% (Miyawaki; Yasuhara; Koh; 1999). In general, the adaptation occurs within 3-5 days; and it is also observed that better responses are related to patients with better perception and self-control (Sergl; Klager et Zentner, 1998). Although it is possible to have reports of pain in 4-24h after the bonding of lingual braces, there is no symtomatology after 7 days. In addition, according to both Ngan; Kess; Wilson; (1989) and to our data, there was no difference between sexes. A curious data is that adaptation response pattern to lingual treatment matches with the medical model, where anxious patients and patients with chronic pain report more discomfort and difficulties for adaptation (Firestone; Scheurer; Bürgin, 1999). In the Table 8, no difference between groups was recorded regarding the way they knew about the certain treatment option. Regarding this question, the most important was the recommendation of dentists and friends; followed by marketing to attract patients. In a panoramic view, our data showed a favorable context for lingual orthodontics, with positive points that indicate how viable and promising this technique is, and that there are many more questions to be studied yet.

Dental Tribuna Books Conclusions • The aesthetics and the fast results were important factors for both techniques. • Lingual patients showed more valorization of the treatment and high level of satisfaction; and they also recognized the functional importance. • Some paradigms regarding lingual treatment are not true (the most reported disadvantages were: high cost for lingual and discomfort for conventional appliances).

References 1. Brosh T, Strouthou S, Sarne O. Effects of buccal versus lingual surfaces, enamel conditioning procedures and storage duration on brackets debonding characteristics. J Dent. 2005 Feb;33(2):99-105. 2. Caniklioglu C, Oztürk Y. Patient discomfort: a comparison between lingual and labial fixed appliances. Angle Orthod. 2005 Jan;75(1):86-91. 3. Firestone AR, Scheurer PA, Bürgin WB. Patients’ anticipation of pain and pain-related side effects, and their perception of pain as a result of orthodontic treatment with fixed appliances. Eur J Orthod. 1999 Aug;21(4):387-96. 4. Hohoff A, Stam T, Ehmer U. Comparison of the effect on oral discomfort of two positioning techniques with lingual brackets. Angle Orthod. 2004 Apr;74(2):226-33.

5. Hohoff A, Fillion D, Stamm T, Goder G, Sauerland C, Ehmer U. Oral comfort, function and hygiene in patients with lingual brackets. A prospective longitudinal study. J Orofac Orthop. 2003 Sep;64(5):35971. 6. Miyawaki S, Yasuhara M, Koh Y. Discomfort caused by bonded lingual orthodontic appliances in adult patients as examined by retrospective questionnaire. Am J Orthod Dentofacial Orthop. 1999 Jan;115(1):83-8. 7. Ngan P, Kess B, Wilson S. Perception of discomfort by patients undergoing orthodontic treatment. Am J Orthod Dentofacial Orthop. 1989 Jul;96(1): 47-53. 8. Sergl HG, Klages U, Zentner A. Pain and discomfort during orthodontic treatment: causative factors and effects on compliance. Am J Orthod Dentofacial Orthop. 1998 Dec;114(6):684-91. 9. Stam T; Hohoff A; Ehmer U. Eur J Orthod. A subjective comparison of two lingual bracket systems. 2005 Aug;27(4):420-6. 10. Wu AK, McGrath C, Wong RW, Wiechmann D, Rabie AB. A comparison of pain experienced by patients treated with labial and lingual orthodontic appliances. Eur J Orthod. 2010 Aug;32(4):403-7. 11. Wu AK, McGrath CP, Wong RW, Rabie AB, Wiechmann D. A comparison of pain experienced by patients treated with labial and lingual orthodontic appliances. Ann R Australas Coll Dent Surg. 2008 Jun;19:176-8.

Lingual Orthodontic Journal

Fabrication of ideal lingual arch wire template with Accurate Bracket Positioner Authors: Pablo Echarri Martín Pedernera Miguel A. Pérez-Campoy

Abstract In this article, a laboratory procedure to determine the ideal arch wire shape in lingual orthodontic treatment using Accurate Bracket Positioner is explained. A photocopy of a model with bonded brackets, data obtained with Accurate Bracket Positioner, standard lingual arch template and a treatment plan are used to describe the procedure of customized template design. Keywords: Lingual Arch Wire ideal shape. Accurate Bracket Positioner.

Introduction Currently, in lingual orthodontic treatments, different ach wire shapes are used. Basically, they are: • Mushroom shape. • Christmas shape. • Lingual straight wire. • 2D customized arch wire. • 3D customized arch wire. The mushroom arch wire designed by Fujita1,2, is one of the most used shapes in lingual orthodontics. It has a distocanine bend to compensate the difference between the buccolingual thickness of a canine and bicuspid. The Christmas arch wire1-10 presents also a distocanine bend just like the mushroom arch wire, but it also has bends between the first and second bicuspid, as well as between the second bicuspid and the first molar to compensate different labio-lingual thicknesses of these teeth. The lingual straight wire proposed by Scuzzo and Takemoto11-13 doesn’t present any compensation bends, therefore, all the compensations are carried out through the bracket base customization. A 2D customized arch wire is carried out when the aim is to bond the brackets with as thin composite layer as possible to optimize the patient’s comfort. In this way, it is necessary to carry out first order bends in the arch wire to compensate different labio-lingual

thicknesses of the teeth. Both horizontal and vertical bends are carried out in this arch wire. In 3D customized arch wire, besides horizontal and vertical bends, torque bends are also carried out to compensate the bonding of the brackets. Hong and Kyung9 made a subdivision of a mushroom shape. There is a basic mushroom shape with a bend between the lateral incisor and a canine, between the canine and bicuspid, and between the bicuspid and the molar (Christmas arch wire) and there is a simplified mushroom shape, which has only a distocanine bend. Also, they describe a Plain Mushroom Archwire, which is flat, and a Step-down Bend Mushroom Archwire, which compensates the difference in bonding height between canines and bicuspids. This kind of a bend was also described by Echarri6,10. Hong and Kyung also describe a Reverse Curve Mushroom Archwire, with sagittal compensation curve9, a Space Closing Mushroom Archwire, which has closed “I” loop at the inner end of the distocanine bend, and an omega loop to mesial of the molar tube; a Modified Space Closing Mushroom Arch wire, with an “I” loop at the inner end of the distocanine inset, and a crimpable hook to distal of the closing loop or to mesial of a molar tube; and a Differential Mushroom Archwire, used in Detailing and Finishing phase, has vertical “I” loops and horizontal “L” loops. As far as the Reverse Curve Mushroom Archwire is concerned, numerous authors have described its increased Spee curve in upper arches and the rever-

Dental Tribuna Books se curve in lower arches used to control the vertical bowing effect and overbite14,15,16.

Different ways to design an ideal arch wire 1. I n CLASS System Technique, set-up models are carried out, they are corrected and an ideal lingual arch wire is adapted over the corrected set-up model. After ligating the brackets to the ideal arch wire, and before bonding them to the model, the last arch wire adjustment is carried out3,10. 2. F illion4,5 designed a software for ideal lingual arch wire template design, called DALI (Dessin Arc Linguale Informatise) having in mind labio-lingual thickness of different teeth. 3. T homas Creekmore17 recommends the adaptation of lingual arch wire directly over the model when lingual brackets are already bonded on the model, using the Slot Machine. 4. S cuzzo and Takemoto11 mark the following references for lingual arch wires design:

a) Li point: it is the most prominent point of the lingual surface of the tooth. This point marks the horizontal position of lingual brackets.

b) Lingual Crown Height (LCH): Vertical dimension of each clinical crown.

c) Embrasure line: defined by Andrews. It joins all the contact points.

d) Lingual Straight Plane (LS Plane: The plane which joins vertical positions of the brac-

Fig. 1. Accurate Bracket Positioner (ABP). Laboratory machine for labial or lingual brackets positioning on the model with customized prescription in indirect bonding technique.

kets slots in posterior teeth and which extends to anterior teeth.

e) Bracket Height (H): The distance between the incisal edges and LS Plane.

5. For lingual arch wire fabrication using the Accurate Bracket Positioner (ABP) (Fig. 1), we use the modification of an arch wire fabrication with the Slot Machine, described by Echarri and Baca6.

Fabrication of ideal lingual arch wire with Accurate Bracket Positioner When the ABP is used to bond the lingual brackets on the model without carrying out the set-up model18-22, lingual brackets are positioned on the model orienting the slot according to the prescription indicated by an orthodontist. In this way, we achieve the prescription customization which can be resumed as the following scheme: • Height: Canine-to-canine brackets should be bonded at the same height. Bicuspids and molars of the same hemiarch should be at the same height, too. The distocanine inset is flat if it is possible to bond both anterior and posterior teeth at the same height. If this is not a case, the differences among these three segments should be compensated. • In-out, alignment: In-out should not be modified between the canines, except if the canines are too spherical. The difference between the canine and bicuspid thickness should be measured with the ABP, to establish the measures of the arch wire inset. If the difference between labio-lingual diameters of bicuspids and molars is not significant, it is possible to compensate it with the bonding. If this is not possible, this difference should be measured and compensated in the arch wire. In such cases, the inset is carried out in the finishing arch wire, but not in the working arch wire, in order to make the space closure possible (sliding mechanics). • Rotation: Usually, a 10-15% rotation overcorrection is included in brackets positioning. The objective is to complete the correction of the initial rotation by compensating the minimization of the arch wire force, and not the final overcorrected position. • Inclination: In canine distalization, the inclination increases for 3 mm to facilitate the root

Dental Tribuna Books movement. Bicuspids and molars are bonded in a usual way, although the anchorage loss is indicated, because root mesialization is obtained through the sagittal curve of the arch wire: the reverse Spee Curve in mandible, and the increased Spee Curve in maxilla. • Torque: The upper incisors torque is increased for 4º in cases in which the “en masse” retrusion of more than 3 mm is indicated, and it is reduced for 4º in cases in which the protrusion of more than 3 mm is necessary. If the lower incisors roots require protrusion, they are bonded with the -4º torque and in cases without the incisors protrusion, with -1º torque. These prescription modifications can be carried out with great precision using the ABP. The composite bracket base allows the customization of the brackets bonding according to the desired prescription and their adaptation to each tooth anatomy. The concept used to carry out this kind of customization has been already studied by different authors7,8,10,16. In lingual technique, the indirect bonding is a must because it is extremely hard to carry out a precise direct bonding; there is a great variety of lingual surfaces anatomy23-25 of the teeth, which can modify the bracket-enamel adjustment; the possibility to customize the prescription; as well as due to different incisor torque requirements26-30 according to the facial type and initial overjet. As Creekmore and Kunik established, the prescription individualization is carried out to compensate the mechanical defects of the straight arch wire technique: the arch wire “play” inside the slot, manufacturing tolerance, progressive reduction of the arch wire force as its deflection reduces, and the impossibility to apply the forces in the dental resistance center (Echarri10,31). The orthodontist should put these prescription modifications on record for the laboratory technician who positions the brackets on the model. The technician should put on record the parameters he uses to position the brackets, and he should photocopy the model with bonded brackets. It is convenient to carry out the first arch template before the fabrication of the transfer tray so you can check the adjustment of the arch wire. Later, if it is necessary to carry out a mini-tray for only one tooth to rebond the bracket, you should have the initial parameters so you can reproduce the positioning with precision.

Customized template design for ideal arch wire shape The necessary elements are: a) Occlusal photocopy of a model with bonded brackets. b) Standard lingual arch wire shape template. c) Treatment plan. d) ABP brackets positioning values table. e) Papel de acetato. The following templates are carried out: a) Working arch wire template. b) Finishing arch wire template. The difference between these templates is in posterior zone: the working arch wire is straight from the post-canine inset towards distal, to allow sliding of the arch wire. The finishing arch wire should compensate the differences in in-out and height that might exist between bicuspids and molars with bends; both arch wires are the same if bicuspids and molars can be bonded with the same parameters, and in this case the posterior sectors are straight6. It is also possible to carry out only one arch wire, but with differences in posterior teeth, when there is no need for sliding mechanics (non-extraction cases and without spacing) in cases in which the length of a dental arch remains the same. In such cases, 1st order bends can be incorporated into the arch wire (alignment/leveling) from the first arch wire.

Anterior arch wire zone design As it has been already said, the canine-to-canine section is straight, and for this, it is necessary that the incisors and canines brackets are bonded at the same height and alignment. Rotations and torques are also customized with bonding. When positioning the brackets in lingual technique the height is determined by the tooth height and by the cingulum shape (especially in canines). The ideal position of brackets is 2 mm from the incisal edge and 1 mm from the gingival margin. The height to which bicuspid and molars brackets are positioned depends on their clinical crown and it doesn’t have to be the same as in anterior sector, and it also can be different in right and in left posterior sector. If the

Lingual Orthodontic Journal bonding height is the same in all three sectors, the post-canine inset is at the same horizontal plane, and the arch wire can rest on a completely flat surface. On the other hand, this inset is also used to compensate any variations in height that might appear between the anterior and posterior sectors. Resuming: if vertical ABP readings in all three sectors are the same, the arch wire is flat. The distocanine inset has a vertical step whose size is equal to the difference between the bonding height parameters of the anterior and posterior sector. In horizontal point of view, the inset dimension is established according to the differences between in-outs of the anterior and posterior sector bonding. Both measures are indicated in a customized template. Superimpose the standard lingual arch wire template on the model photocopy, select the size that fits the best to your needs. The arch wire line of the template should be superimposed on the area of the brackets slots. When we verify the anterior curvature and the in-set size, both in horizontal and in vertical, we have to establish the anterior curvature length or the point in which the in-set should be carried out. The distance between the in-sets should be at least equal to the sum of mesio-distal diameters of canines and incisors. There can be three cases: 1. Anterior segment remains the same. In this case, there is no crowding nor spacing, and therefore a 1 mm in-set to distal of the canine bracket is carried out. 2. Anterior segment should increase its length. In this case, there is crowding and the distance between in-sets should allow the alignment, and therefore it has to be longer than the distance between the brackets for as many millimeters as the crowding. 3. Anterior segment should reduce its length. In this case, there is spacing, or the stripping is carried out, therefore, the 1st arch (working arch) is equal to the distance between the canine brackets. When the spaces are closed, next arches should be able to reduce the anterior segment length to close the space between the canines and the bicuspids. In extraction cases, the inset situation also depends on the way in which the extraction space is mana-

ged. Initial canine distalization is carried out with the 1st arch wire. The canine should be distalized enough so the anterior segment can be aligned, i.e., the anterior dento-alveolar discrepancy (canine-to-canine) should be at zero. The cephalometric discrepancy is not taken into account because in lingual technique, â&#x20AC;&#x153;en masseâ&#x20AC;? retraction of canine-to-canine segment is always done due to two reasons: mechanic: the inset between the 3 and 4 makes difficult to distalize separately canines and incisors; esthetic: to avoid creation of a space between the canine and the lateral incisor (which is undesirable by adult patients). Furthermore, the extraction space in adults is covered by an esthetic prosthetic tooth, which is gradually trimmed as the space is closed. For initial distalization, the inset should be carried out by leaving a certain length of an anterior arch, sufficient enough to make effective the movement. This is the procedure in cases in which there is no requirement for anchorage. In cases of maximum anchorage, the inset is positioned in such a way that it makes contact with the bicuspid; in medium anchorage cases, the inset is positioned in the center of the extraction space.

Posterior arch wire zone design In sliding arch wires (working arch wires), posterior sectors have to be straight. In finishing arch wires, they should have 1st order bends (in-out/alignment and height/leveling), necessary for compensation of parameters which couldnâ&#x20AC;&#x2122;t be compensated with the bonding. Antemolar omegas should be carried out, and distal end of the arch wire should be always bent towards labial to avoid discomfort in the tongue. Transverse adjustment of the arch wire should be carried out according to the needs of expansion or contraction of the case. Horizontal and vertical bowing effect compensation curves should also be incorporated in the arch wire. Vertical bowing effect is the same both in labial and lingual arch wires, i.e., there is a tendency to molar mesio-version and extrusion, bicuspids intrusion, and incisors extrusion. It should be compensated with a sagittal curve incorporated in the arch wire to gingival concavity, i.e., upper super-Spee curve and lower anti-Spee curve (equivalent to tip-back). Horizontal bowing effect is the opposite in lingual and labial arch wires. In lingual arches, the tendency is molar distorotation and bicuspid expansion. It should be compensated with the horizontal curve opposite to the

Dental Tribuna Books

Fig. 2. Male 21-year old patient Fig. 3. Initial intraoral central photo- Fig. 4. Initial intraoral left lateral phowith Class I malocclusion and crow- graph. tograph. ding. Initial intraoral right lateral photograph.

Fig. 5. Initial upper occlusal photograph.

Fig. 6. Initial lower occlusal photograph.

ovoid shape which we incorporate in labial arches, i.e., it is equivalent to toe-out. Both curves considered from canines to second molars are 2 mm deep, but this depth is increased when the bowing effect is increased due to the characteristics of the case. Vertical and horizontal bowing effect is increased in: a) Small diameter and more flexible arches.

Fig. 7. Upper model.

b) Extraction cases. c) Wide extraction spaces. d) Space closure arches, both with loops and sliding mechanics.

In these cases, the corresponding (vertical or horizontal) compensation curve depth should be increased, and in the opposite cases, the curve should be reduced.

e) Hyper divergent or dolichofacial patients. Vertical bowing effect increases in: a) Deep bite cases. b) Molar mesio-version. Horizontal bowing effect increases in: a) Molar disto-rotation.

How to draw customized template Finishing arch wire A case with molar Class I malocclusion and crowding in both arches (figs. 2 to 6). Lingual brackets are bonded on the upper model (fig. 7) with the ABP (fig. 8), and the model is photocopied (fig. 9). Youâ&#x20AC;&#x2122;ll need the table with values used to bond the brackets with the

Lingual Orthodontic Journal

Fig. 8. Upper model with Evolution SLT brackets bonded in ABP.

Fig. 9. Occlusal photocopy of the upper model with brackets.

Lleó 11-13 1ª planta 08911 Badalona (Barcelona) – España Tel: +34 93 384 47 05 – Fax: +34 384 41 53 Web: www.centroladent.com – e-mail: lab@centroladent.com

REPORT

INDIRECT BONDING TRAY DOCTOR:………………………………………………………...

CLIENT’S CODE: ……………………………………….....…………

PATIENT: ..………………………………………………………

SHIPMENT DATE: …………………………………………………..

CASE DATA UPPER LOWER

LINGUAL X LINGUAL 

LABIAL  LABIAL 

.018” X .022” .018” .022”

TRAY  SILICON  TRANSPARENT SILICON  DOUBLE TRAY X SMART JIG

BRACKET: Evolution SLT BRACKET: …………………………………

TRAY CUT  1 PIECE  2 PIECES  3 PIECES

ABP CASES MAXILLA TOOTH

IN-OUT

MANDIBLE BRACKET

TOOTH

TORQUE

INCLIN.

HEIGHT

IN-OUT

ROTAT.

+12º

+5º

TORQUE

+8º

+9º

-0,5º

2ºDR

-2º

+13º

+0,5º

2ºDR

-7º

0º

-7º

0º

-14º

0º

-14º

0º

+12º

+5º

+8º

+9º

-0,5º

-2º

+13º

+0,5º

2ºDR

-7º

0º

-7º

0º

-14º

0º

-14º

0º

INCLIN.

HEIGHT

IN-OUT

BRACKET HEIGHT

IN-OUT

ROTAT.

OBSERVATIONS

Fig. 10. Laboratory report for brackets bonding on the model with ABP.

Dental Tribuna Books

Fig. 11. Measuring of the height of the brackets bonding with ABP.

Fig. 12. Measuring of the in-out of the anterior teeth brackets bonding with ABP.

Fig. 13. Measuring of the in-out of the bicuspid brackets bonding with ABP.

Fig. 14. Measuring of the in-out of the molar brackets bonding with ABP.

Fig. 15. Superimposition of the standard arch wire template on the model photocopy.

Fig. 16. Superimposition of the acetate sheet on the standard arch wire template and the model photocopy.

ABP (fig. 10). The figure 11 shows the height reading used to bond all the brackets at 10 mm. The figure 12 shows the in-out used to bond anterior teeth at 18 mm. The figure 13 shows the in-out used to bond the bicuspid brackets at 20 mm, and the figure 14 shows the in-out used to bond the molar brackets at 21 mm.

Superimpose the selected curve of standard lingual arch wire template on the canine-to-canine slots area of the photocopy (fig. 15).

Superimpose the acetate sheet over the template (fig. 16), and draw the anterior arch wire curve (fig. 17). In this case, the anterior discrepancy is -3 mm,

Lingual Orthodontic Journal therefore, 1.5 mm is added to the anterior ach wire curve on each side (figs. 18 and 19).

the horizontal and vertical values on record (figs. 20 and 21).

Draw disto-canine insets, using the horizontal measurement from the parameter list (fig. 10), and put

Select the straight line which corresponds to the line of bicuspid and molar brackets slots. In expansion or

Fig. 17. Drawing of the anterior part of the arch.

Fig. 18. As anterior dento-alveolar discrepancy is -3 mm, the anterior zone of the arch wire extended for 1.5 mm at each side.

Fig. 19. Anterior zone of the arch wire with compensated dento-alveolar discrepancy.

Fig. 20. Measuring of the disto-canine in-set.

Fig. 21. Drawing of the disto-canine in-sets of 2 mm.

Fig. 22. Drawing of the bicuspid zone of the arch wire.

Dental Tribuna Books

Fig. 23. Measuring of the ante-molar in-set.

Fig. 24. Drawing of the ante-molar in-set.

Fig. 25. Drawing of the molar zone.

Fig. 26. Finished customized template of finishing arch wire.

molar brackets are bonded with different in-out as in this case, draw a line passing through the slots of the bicuspid brackets (fig. 22). Mark the antemolar inset, in this case, it is 1 mm (figs. 23 and 24), and draw the arch wire line passing through the molar tubes (fig. 25). Draw a mark at mesial and distal end of the last molar tube as a reference for omega loop and distal bend. Working arch wire

Fig. 27. Finished customized template of working arch wire.

Working arch wire is carried out when it is necessary to carry out mesio-distal movements of posterior teeth, and there canâ&#x20AC;&#x2122;t be any insets between molars and bicuspids. The template is drawn in the same way as the finishing arch wire template, but the bicuspid zone of the arch wire is straight up to the molars.

contraction cases, draw another dotted line contracting or expanding the arch wire. If the bicuspid and

The figure 26 shows the finished finishing arch wire template and the figure 27 shows the working arch

Lingual Orthodontic Journal

Fig. 28. Ligating of the first arch wire. Observe that the anterior zone of the arch wire is overextended to facilitate the protrusion.

Fig. 29. Case evolution.

wire template. It is convenient to carry out the 1st arch wire in the laboratory according to the template and to check it on the model with bonded brackets (before fabrication of the transfer tray), to check for any differences between the photocopy and the model. If the arch wire doesnâ&#x20AC;&#x2122;t fit to the model, the template must be corrected.

application (DALI, software for computer-aided design of lingual arch wires), also stressed the importance of an occlusogram in the treatment plan.

The figure 28 shows the first ligated .022â&#x20AC;? Thermic NiTi archwire. Observe that the arch wire is compressed in anterior zone to allow the incisors and canine alignment after the protrusion movement is done. The arch wire still cannot be ligated in all brackets. The figure 29 shows the progress of the treatment. The alignment is partially finished, and the arch wire is not compressed any more, but it still cannot be inserted in all brackets.

Conclusions A detailed procedure has been described on how to carry out the customized templates of working and finishing lingual arch wires for indirect bonding, reducing the chair time. From our experience, we can confirm that very rarely we have to correct the template, but there are obviously more precise methods to obtain 1:1 ratio occlusograms. Dr. Charles Burnstone (Connecticut University) designed the first photo camera for occlusograms, the Occlusal Tracer (Behavioral Motivations, Hobbs), and the very same Dr. Burnstone published computer-aided occlusograms for the first time in 1979. Soon, Marcotte33 (Occlusal VTO manual, based on Simon and Burnstone), Ricketts33 (computer-aided occlusogram), and Didier Fillion4,5 with his lingual

It is also important to underline Larry Whiteâ&#x20AC;&#x2122;s34-37 works with occlusograms and it use, drawing the upper and lower arches and superimposing them to check the occlusion. He stressed the importance of their use in customized arch wire shapes fabrication, measuring of dento-alveolar discrepancy, checking of upper-lower Bolton discrepancy, occlusal simulations and evaluation of different treatment plans. We38 also use the occlusogram, carry out the occlusal VTO to correct the set-up models in cases of diagnostic set-up, CLASS System, elastic positioners and surgical splints. When the occlusal VTO is drawn, it is positioned over the OPI (Occlusal Plane Indicator) and on the model mounted in SAM, and in this way the lower model can be corrected according to the VTO, keeping the same occlusal plane. To check the design of the arch wire carried out as it has been explained in this article, you can carry out an occlusogram and occlusal VTO and superimpose the template on the VTO.

References 1. Fujita K. New orthodontic treatment with lingual bracket and mushroom archwire appliance. Am J Orthod 1979;76:657-75. 2. Fujita K. Multilingual-bracket and mushroom arch wire technique. A clinical report. Am J Orthod Dentofacial Orthop 1982;82:120-40.

3. Scholz RP, Swartz ML. Lingual Orthodontics: A Status Report: Part 3. Indirect Bonding – Laboratory and Clinical Procedures. J Clin Orthod 1982;16:81220. 4. Fillion D. Orthodontie Linguale: Systemes de Positionnemet des Attaches au Laboratorie. L’Orthodontie Francaise 1989;60:695-704. 5. Fillion D. A la recherche de la précision en technique á attaches linguales. Rev Orthop Dento Faciale. 1986;20:401-13. 6. Echarri P, Baca A. Ortodoncia lingual. Determinación de la forma del arco. Revista Iberoamericana de Ortodoncia. 1998;17:1-8. 7. Echarri P. Procedimiento para el posicionamiento de brackets en ortodoncia lingual. (Parte I). Ortod Clin. 1998;1(2):69-77. 8. Echarri P. Procedimiento para el posicionamiento de brackets en ortodoncia lingual. (Parte II). Ortod Clin. 1998;1(3):107-17. 9. Hong R, Kyung H. Lingual Orthodontic treatment. Mushroom Archwire Technique and the lingual Bracket. Daegu (Korea): Dentos Co. Ldt; 2009. p. 24-7. 10. Echarri P. Lingual orthodontics. Complete technique, step by step. Barcelona (Spain): Nexus Ediciones S.L.; 2003. 11. Scuzzo G, Takemoto K. Invisible Orthodontics. Current concepts and solutions in lingual orthodontics. Germany: Quintessence Books; 2003 p. 145-155 12. Takemoto K, Scuzzo G, Lombardo LU, Takemoto YU. Lingual straight wire metod. Int Orthod. 2009;7(4):335-53 13. Lombardo L, Saba L, Scuzzo G, Takemoto K, Oteo L, Palma JC, Siciliani G. A new concept of anatomical lingual arch form. Am J Orthod Dentofacial Orthop 2010;138(3):260.e1-260.e13; discussion 260-1 14. Echarri P. Comparación del cierre de espacio con diferentes mecánicas de deslizamiento en ortodoncia lingual. Rev Esp Ortod. 2004;34(2):139-47. 15. Echarri P. How to obtain the maximum benefits from lingual archwires. J Japan Ling Orthod Assoc. 2002;13:2-13. 16. Echarri P. Lingual Orthodontics. Bracket set-up using Model Checher, Slot Machine, and CRC Ready Made Core Trays. Korean J Lingual Orthod. 2003; 2:58-71. 17. Creekmore TD. Lingual Orthodontics: Its Renaissance. Am J Orthod Dentofacial Orthop. 1989; 962:120-37 18. Echarri P, Pedernera M. Ortodoncia lingual simplificada. Técnica CLO3. Tribuna Books Ripano Lingual Orthod J 2014;(1):17-21. 19. Echarri P, Pedernera M, Perez-Campoy MA. Técnica CLO3: Una solución ortodóncica estética para las malposiciones de los dientes anteriores. Dental Tribune Spain 2014;9(2):6-9. 20. Echarri P, Pedernera M, Schendell C. Der Accurate Bracket Positioner (ABP) – präzise Bracketposi-

tionierung ohne Set-up.Kieferorthop Nachrichten 2014;(4);18-20. 21. Echarri P, Pedernera M, Perez-Campoy MA. Protocolo de laboratorio para el montaje de brackets linguales sin modelos set-up. Accuracy Bracket Positioner. Tribuna Books Ripano Lingual Orthod J 2014;(2):16-22. 22. Echarri P, Pedernera M, Pérez-Campoy MA. Individuelle Einzelzahnsteuerung bei lingualen Apparaturen. Kieferorthop Nachrichten 2014;(7+8);23-5 23. Creekmore TD, Kunik RL. Straight wire: The next generation. Am J Orthod Dentofacial Orthop. 1993; 104:8-20. 24. Taylor NG, Cook PA. The reliability of positioning pre-adjusted brackets: An In vitro Study. BJO. 1992; 19(2):25-34. 25. Taylor RMS. Variation in form of human teeth: II. An anthropologic and forensic study of maxillary canines. J Dent Res. 1969; 48(2):173-82. 26. Ross VA, Isaacson RJ, Germane N, Rubenstein LK. Influence of vertical growth pattern on Facio-lingual inclinations and treatment mechanics. Am J Orthod Dentofacial Orthop. 1990; 98:442-29. 27. Vardimon AD, Lambertz W. Statistical evaluation of torque angles in reference to straight-wire appliance (SWA) theories. Am J Orthod. 1986; 89(1):56-66. 28. Germane N, Bentley BE, Isaacson RJ. Three biologic variables modifying faciolingual tooth angulation by straight-wire appliance. Am J Orthod Dentofac Orthop. 1989; 96(4):312-9 29. Balut N, Klapper L, Sandrick J, Bowman D. Variations in bracket placement in the preadjusted orthodontic appliance. Am J Orthod Dentofac Orthop. 1992; 102(1):62-7 30. Creekmore TD. Interview on torque. J Clin Orthod 1979;13:305-10. 31. Echarri P. Diagnóstico en ortodoncia. Estudio multidisciplinario. 2ª ed. Barcelona (España): Nexus ediciones SL; 2003. 32. Marcotte MR. The use of occlusogram in planning orthodontic treatment. Am J Orthod 1976;69(6):655-67. 33. Ricketts RM, Roth RH, Chaconas SJ, Schulhof RJ, Engel GA. Orthodontic Diagnosis and Planning. Rocky Mountain Orthodontics 1982, Vol. 1 y Vol. 2. 34. White LW. Individualized ideal arches. J Clin Orthod 1978;12(11):779-87. 35. White LW. The clinical use of occlusograms. J Clin Orthod 1982;16(2):92-103. 36. White LW. A technique for indirect archwire construction. Angle Orthod 1973;43(4):444-7. 37. White LW. The clinical use of occlusogramas. JCO 1982;16(2):92-103. 38. Echarri P, Pedernera M. Oclusograma y objetivo visual oclusal de tratamiento (OVT Oclusal). Interrelación con el cefalograma lateral. Tribuna Books Ripano Lingual Orthod J 2013;(0):11-22.

XII Congreso 12th Congress Del 30 de junio al 3 de julio Atenas, Grecia 2016 From june 30th to july 3rd Athens, Greece 2016

EUROPEAN SOCIETY OF LINGUAL ORTHODONTICS Evidence Based on Lingual Orthodontics Reserve su fecha Reserve the date

R E L

S E B

L E S

New approach to lingual Orthodontics Authors:

Dr. Pablo Echarri Lobiondo Dr. Kyoto Takemoto Dr. Giuseppe Scuzzo Dr. Didier Fillion Dra. Silvia Geron Dr. Hee Moon Kyung Dr. Mario Paz Dr. François Leclerc Dr. Marcelo Marigo

428 pages in full color Dimensions: 21x29.7 cm Luxurious hard cover binding ISBN: 978-84-937793-0-6 Price: 120 euros - Shipping price for Europe: 36 euros = 156 euros - Shipping price for America: 46 euros = 166 euros

OFFER: 80 euros (shipping included)* PROLOGUE Having had our previous two WSLO Congresses in two different continents, in New York in 2006 and Seoul in 2007, we held our 3rd biennial Congress in March of this year at Buenos Aires with South America as our 3rd new continent. I’m very glad that so many orthodontists could attend this Congress and could see the newest and the highest level of treatments in lingual orthodontics in the world. I would especially like to say thank you for the efforts of the chairman Dr. Pablo Echarri, Dr. Adriana Pascual and Dr. Fernanda Elgoyhen, the Presidents of SAO and SAOL. Furthermore, I would like to say a very big thank you to all the staff and volunteers, too many to name individually here, who worked so hard to make the 2009 congress such a success. I think that everybody appreciates that putting together such a good event takes a great deal of work and dedication. In addition, I sincerely hope that everybody will appreciate that this book is the result of many hours of work and research by the speakers at the Congress who gave us so many excellent presentations. These speakers have greatly helped in our mission to advance the art and science of lingual orthodontics and to help us to promote the use of lingual orthodontics throughout the world. I hope everybody will make the best use of this book to understand current trends in lingual orthodontics. I hope everybody will take the opportunity to present their ideas and help extend the art and science of lingual orthodontics when we hold our next Congress which will be in Osaka, Japan in April 2011. The WSLO is always seeking to achieve the highest possible quality of lingual orthodontics. Let us look forward together to a promising future.

ORDERS: You can order the book, indicating the offer, by: • E-mail: ripano@ripano.eu • Phone: (+34) 91 372 13 77 • Fax: (+34) 91 372 03 91 • Mail: Ripano S.A. Ronda del Caballero de la Mancha, 135 - 28034 Madrid (Spain) • On-line: www.ripano.eu *Offer is valid while supplies last.

CONTENTS 1. Pascal Baron, Cristophe Gualano. Anchorage control performed with mini-screws and the LingualjetTM appliance 2. Regina Bass. Anchorage in lingual orthodontics 3. Germain Becker. Clinical pathways in lingual orthodontics 4. Tamar Brosh y col. Theoretical analysis of maxillary incisors movement due to antero-posterior force: labial vs. lingual orthodontics 5. Julio Cal-Neto. Advantages of the straight wire technique in lingual orthodontics 6. Asif Chatoo. Interdisciplinary management of adult patients with lingual braces 7. Claudia Correga Andreica y Dario Bertossi. Tissue reaction to light orthodontic forces – a comparison of STb versus Damon appliance 8. Juan Carlos Crespi y Marcos López Rubio. Study group of lingual orthodontics (SGLO). Starting the way 9. Antonio D’Alessandro y Livia Nastri. Advanced active retainer: fixed lingual orthodontics with no brackets 10. Rubens Demicheri. Leveling and systemized treatment mechanics with the Magic® Lingual system 11. Pablo Echarri. Skeletal anchorage in lingual orthodontics 12. Mª Fernanda Elgoyhen y José Carlos Elgoyhen. Therapeutic alternatives with lingual orthodontics 13. Ryuzo Fukawa. Lingual orthodontics in the new era: Treatment according to criteria for occlusion and aesthetics 14. Ricardo Gallardo. Retraction of lower anterior teeth with reduced anchorage loss without using miniscrews 15. José Gaspar y Vivian K. Granadino Gaspar. 20 years of lingual orthodontics in Brazil 16. Silvia Geron. Management of the vertical dimension in severe anterior open bite (AOB) 17. Alfredo Gilbert Reisman. A new in-house lingual bracket transfer system 18. Ana González Blanco. Clinical management of the lingual orthodontic appliance 19. Diana Grandi. Lingual orthodontics and speech – language therapy: the benefits of interdisciplinary team work 20. Julia Harfin. Paradigms in lingual orthodontics 21. Chiori Hashiba. Incisal embrasure and incisal edge: their efficacy of the aesthetic appearance of maxillary anterior teeth 22. Mª Esther Hidalgo. Clinical and laboratory evolution in lingual technique 23. Toru Inami. Clinical standards of the establishment for facial balance and harmony in lingual bracket orthodontic technique 24. Aurelio Jano Takane. Goodbye mushroom 25. Hee-Moon Kyung. Lingual plain wire appliance and microimplant anchorage 26. Hee-Moon Kyung. Microimplants as anchorage in orthodontics 27. Roberto Lapenta. How to obtain success with lingual orthodontics? 28. Jean François Leclerc y col. Partial case report: how to manage lingual treatment with an edentulous anterior teeth patient? 29. Christophe Lesage. Mini screws in orthodontics: contribution of the 3D cone beam in surgical technique 30. Hatto Loidl. Selfligation in lingual technique 31. Marcos López Rubio. From simple to complex 32. Marcelo Marigo y Valter Arima. A new concept for lingual bracket – a point of view 33. Francisco Martino. Lingual orthodontics FAQ 34. Isao Matsuno. Surgical orthodontic treatment in lingual orthodontics 35. Carla Melleiro y col. Evaluation of cephalometric alterations noted during the lingual orthodontic treatment 36. Eliakim Mizrahi. Miniscrews, auxiliaries and lingual orthodontics 37. Nayre Mondino. Class II. Treatment – lingual orthodontics 38. Ramiro Moreno. Small movements and laboratory procedures 39. Magali Mujagic. Lingual orthodontics for each patient: a reality in a daily practice 40. Christine Muller. Contribution of micro-screws to Class II treatment 41. Marino Musilli. The interdisciplinary approach with the bracketless fixed orthodontics 42. Manabu Nakagawa. Bracket “Evolution”: characteristics and case reports 43. Carlos Navarro y col. Development of the “In-Ovation-L” bracket from GAC 44. Thomas Örtendahl. Clinical experience of selfligated aesthetic directbond lingual bracket 45. Mª Giacinta Paolone y col. Lingual orthodontics: a means for osseous and tissue regeneration, conventional treatment and forced eruption 46. Mª Elsa Pavic. Vertical management in lingual technique: advantages and disadvantages 47. Mario Paz. Lingual and other accessory aesthetic techniques 48. Lucas Prieto. Prieto’s hygiene-friendly pendulum 49. Marcos Prieto. Prieto Lingual Straight-Wire Bracket (PSWb) 50. Caterina Pruzzo. Progress in lingual orthodontics, 8 years of clinical experience 51. Ronald Roncone. Lingual you will love 52. Florence Roussarie. Microscrews and the lingual system: an efficient working combination for the patient 53. Toru Shigeeda. Where is the best placement of micro implants, mid-palatal or alveolar bone or both? 54. Kyoto Takemoto y Giuseppe Scuzzo. New STb lingual straight wire method 55. Rita Thurler y col. Aluminum oxide – to use or not to use? 56. Henrique Valdetaro. Lingual orthodontics: problems and solutions 57. Emma Vila Manchó. Lingual orthodontics lesions vs. labial orthodontics lesions 58. Milena Zulic. Miniimplants as biomechanical auxiliaries in lingual orthodontics

Diagnóstico y Plan de Tratamiento en Ortodoncia Author: Pablo Echarri

More than 555 full color pages Size: 21x29,7 cm. Hard cover binding ISBN: 978-84-942601-0-0 More information: www.ripano.eu CONTENTS Prólogo Capítulo 1: Importancia del diagnóstico en ortodoncia. Concepto del diagnóstico en la Técnica CSW Capítulo 2: Clasificación de las maloclusiones Capítulo 3: Historia clínica. Examen clínico Capítulo 4: Estudio de modelos por edades. Estudio de la ortopantomografía Capítulo 5: Registros y montaje en articulador. Zocalado de modelos Capítulo 6: Estudio con MPI y conversión de la cefalometría de máxima intercuspidación (MI) a relación céntrica (RC). Capítulo 7: Fotografía en ortodoncia Capítulo 8: Cefalometría Capítulo 9: Estudio funcional. Protocolo de exploración interdisciplinaria en niños y adultos Capítulo 10: Estudio de las vías aéreas en la telerrediografía de perfil Capítulo 11: Estudio de las rotaciones Capítulo 12: Predicción de crecimiento sin tratamiento Capítulo 13: Objetivo visual de tratamiento Capítulo 14: Cefalometría frontal Capítulo 15: Estudio estético Capítulo 16: Evolución de la cara una vez terminado el crecimiento Capítulo 17: Discrepancia dento-alveolar. Discrepancia anterior. Discrepancia posterior. Predicción de erupción de terceros molares. Manejo de la discrepancia Capítulo 18: Elaboración del plan de tratamiento

ORDERS: You can order the book, indicating the offer, by: • E-mail: ripano@ripano.eu - Phone: (+34) 91 372 13 77 - Fax: (+34) 91 372 03 91 • Mail: Ripano S.A. Ronda del Caballero de la Mancha, 135 - 28034 Madrid (Spain) • On-line: www.ripano.eu

Diagnóstico y Protocolos de tratamiento en Ortodoncia y Ortopedia Dentofacial Authors: Bernardo García Coffín & Pedro Colino Gallardo

More than 250 full color pages Size: 28,5 x 28,5 cm. Hard cover binding ISBN: 978-84-942601-7-9 NEXT NOVELTY More information: www.ripano.eu CONTENTS PRIMERA PARTE

2. D iagnóstico sobre estudio de modelos

I. Introducción

3. D isarmonías dento-dentaria: análisis de Bolton

1. Epidemiología 2. ¿Por qué y cuando comenzar un tratamiento ortodóncico precoz? a. E stablecimiento de la oclusión en dentadura temporal. (A. Patti)

IV. Fotografías

5. Elastodoncia 6. Estabilización – Anclaje 7. Retención 8. Aparatología Fija multibrackets

1. Introducción

CUARTA PARTE

2. Términos básicos

A. ARCOS Y BRACKETS

b. Constitución de dentadura mixta

3. Material necesario

1. Brackets

c. D iferente evolución de los primeros molares permanente en función del tipo de plano terminal (Moyers, 1977)

4. Tipos de fotografías

2. Arcos

3. Duración de tratamiento

V. Radiografías 1. ortopantomografía 2. Telerradiografía SEGUNDA PARTE

4. Aparataje

CLASIFICACIÓN DE LAS MALOCLUSIONES

II. Diagnostico 1. Ficha administrativa 2. Historia clínica 1. E nfermedades generales del paciente

1. Maloclusión Clase I 2. Maloclusión Clase II división I 3. Maloclusión Clase II división II

3. R esumen de los tamaños de arcos y utilización 4. Sistema Garcia-Coffin B. MATERIALES E INSTRUMENTAL 1. Alambres 2. Elásticos-gomas 3. Instrumental QUINTA PARTE

4. Maloclusión Clase III

A. Llaves de Oclusión

2. Patologías previas

5. Maloclusiónes Transversales

B. Reglas de Oro

3. Motivo principal de consulta

6. Mordida Abierta

C. Conceptos Ortopédicos

4. Resumen de hallazgos clínicos

7. Sobremordida profunda

D. ATM

5. Hábitos

8. Asimetrías Craneofaciales

E. Protocolos de tratamiento

6. Reeducación

TERCERA PARTE

1. Maloclusión Clase I

7. Tratamientos odontológicos previos.

APARATOLOGIA

2. Maloclusión clase II

8. Anomalías dentarias III. Estudios de modelos 1. Recorte y presentación de modelos

1. Placas removibles

3. Maloclusión clase III

2. Expansor rápido del paladar

4. Anomalías verticales

3. Auxiliares

5. Asimetrías

4. Aparatos funcionales

6. Circunstancias especiales

Tratamiento Ortodóncico con Extracciones Author: Pablo Echarri

More than 300 full color pages Size: 21x29,7 cm. Hard cover binding ISBN: 978-84-937238-3-5 More information: www.ripano.eu

Handbook for modern functional treatment approaches and techniques Authors: Michael Gorbonos, Toshio Kubodera, Bakr Rabie, Brian Preston

364 full color page Size: 21x29,7 cm. Hard cover binding ISBN: 978-84-940554-7-8 More information: www.ripano.eu

Ortodoncia y Microimplantes. Sardac Technique (2ª edición) Authors: Pablo Echarri and Lorenzo Favero

More than 450 full color pages Size: 22x31 cm. Hard cover binding ISBN: 978-84-940232-2-4 More information: www.ripano.eu

Ortodoncia y Ortopedia con Aparatos Funcionales. 2ª edición Author: Juan José Alió Sanz

268 full color pages Size: 21x29,7 cm. Hard cover binding ISBN: 978-84-940232-4-8 More information: www.ripano.eu ORDERS: You can place order by indicating the offer you are interested in by: • E-mail: ripano@ripano.eu - Phone: 91 372 13 77 - Fax: 91 372 03 91 • By regular mail: Ripano S.A. Ronda del Caballero de la Mancha, 135 - 28034 Madrid • Through our web site: www.ripano.eu

Desde el Arco Recto Convencional al Sistema Damon. Mis Caminos Diagnósticos y Mecánicos Author: Alfredo Nappa Aldabalde

More than 680 full color pages Size: 23x32 cm. Hard cover binding ISBN: 978-84-936756-2-2 More information: www.ripano.eu

Tratamiento Ortodóncico y Ortopédico de 1ª Fase en Dentición Mixta. 2ª Edición Author: Pablo Echarri Lobiondo Collaborators: William Clark, Emma Vila Manchó, Jordi Coromina and José Duran von Arx

More than 525 full color pages Size: 23x32 cm. Hard cover binding ISBN: 978-84-612-5814-7 More information: www.ripano.eu

Rehabilitación Neuro-Oclusal (RNO) Author: Pedro Planas

388 full color page Size: 16x23 cm. Hard cover binding ISBN: 978-84-940554-9-2 More information: www.ripano.eu

Atlas de Cefalometría y Análisis Facial Authors: Jesús Fernández Sánchez & Omar Gabriel da Silva Filho

More than 290 full color pages Size: 29,7x24 cm. Hard cover binding Special graphic design, relief, special colors, UV varnish, folded pages, etc... ISBN: 978-84-936756-7-7 More information: www.ripano.eu

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Problemas bucales en odontopediatría: Uniendo la evidencia científica a la práctica clínica Authors: Marcelo Bönecker, Jenny Abanto, Maria Salete Nahás Pires Corrêa, José Carlos Pettorossi Imparato & Antonio Carlos Guedes-Pinto

298 full color pages Size: 21x29,7 cm. Hard cover blinding ISBN: 978-84-942601-2-4 More information: www.ripano.eu

Atlas de Odontología Infantil para Pediatras y Odontólogos Author: Elena Barbería Leache

More than 330 full color pages Size: 28,5x28,5 cm. Hard cover binding ISBN: 978-84-941269-9-4 More information: www.ripano.eu

Alineadent. Ortodoncia invisible Author: Jesús García Urbano

More than 230 full color pages Size: 21x29,7 cm. Hard cover binding ISBN: 978-84-941269-8-7 More information: www.ripano.eu

Guía Teórico-Práctica de Clínica Odontológica Integrada en Adultos Author: José Luís Calvo Guirado

294 full color pages Size: 19,5x24,8 cm. Hard cover binding ISBN: 978-84-941269-6-3 More information: www.ripano.eu ORDERS: You can place order by indicating the offer you are interested in by: • E-mail: ripano@ripano.eu - Phone: 91 372 13 77 - Fax: 91 372 03 91 • By regular mail: Ripano S.A. Ronda del Caballero de la Mancha, 135 - 28034 Madrid • Through our web site: www.ripano.eu

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