My first experience with lingual appliances came in the late
1990s, while I was an orthodontic resident at Northwestern
University. The experience was enough to convince me that I never
wanted to touch another lingual case again. However, when GAC
came out with their self-ligating lingual brackets (Innovation-L), it
definitely stirred my interest. When I saw how low-profile the
Innovation-L brackets were and how easy they were to open and
close, I was definitely open to trying out lingual again but only for
anterior alignment cases. As I began treating several limited U3-3
and L3-3 lingual cases and began feeling more comfortable working
with the Innovation-L appliances, I was one of several
SureSmile orthodontists who began lobbying SureSmile to develop
their software applications for lingual as well as for labial. For those
of you who might be interested in learning more about SureSmile
QT, SureSmile QT went into beta testing in January of 2009.
At the 2010 AAO annual meeting, SureSmile released a limited
launch of SureSmile QT that was only available to existing
SureSmile customers who have demonstrated a proficiency in
SureSmile's software applications. Having been actively involved
with the development and testing of SureSmile QT, it is incredible
for me to think how far they have come in only a little more than
18 months. I truly give the SureSmile team a great deal of credit in
being able to develop such an incredible product in such a short
period of time. As a result, I would like to share with all of you a
SureSmile-Lingual case that I just completed last winter.
The patient presented at his new
patient examination as a healthy 41-
year-old adult male. He stated that his
chief complaint was that he wanted to
have a nicer smile. He also stated that
he was a professional airline pilot and
because of his profession he wanted to
be treated with an aesthetic orthodontic
treatment option in as short of treatment
time as possible.
Diagnosis and Etiology
Figure 1: Intraoral examination revealed a Class I molar and
canine relationship on both sides. His overbite (OB) was deep at
60 percent and his overjet (OJ) was tight at 1mm. There was an
increased lower curve of spee and excess upper and lower incisal
wear due to his OB and OJ relationship. Arch length deficiencies
were present in 7mm of his maxillary arch and 7mm in his
mandibular arch. Both maxillary and mandibular arch forms
were asymmetric and tapered. Periodontal evaluation revealed
normal and healthy gingival tissue with no recession present.
Frontal facial evaluation revealed a symmetrical and balanced
facial pattern. Profile facial evaluation revealed a
straight profile with slightly prominent chin. His nasio-labial
angle was 110 degrees and both upper and lower lips were
normal and competent at repose. A frontal smile evaluation
revealed acceptable upper and lower smile lines with buccal
Figure 2: Cephalometric analysis revealed a Class I skeletal
relationship with ANB=2. It also revealed a brachiocephalic
facial pattern with a low MPA=26. His U1-SN=99 and
IMPA=99 degrees were both within normal limits.
Figure 3: Panoramic evaluation revealed that all third molars
had been extracted. Alveolar bone height in both maxillary and
mandibular arches looked healthy and within normal limits.
There were no other significant findings present.
The patient had requested to be treated with SureSmile and
Innovation-L lingual fixed appliances due to his desires to be
treated with an aesthetic orthodontic appliance and in the
shortest treatment time possible. As a result, the lingual amalgam
present for his UL2 needed to be replaced with a composite
restoration by his general dentist prior to the placement of
his Innovation-L brackets.
On February 24, 2009, 0.018 Innovation-L (GAC) fixed
appliances were placed for U7-7 and L7-7 using our practice's
indirect bonding technique. The UR2, LL1 and LR3 were
not bonded due to significant rotations. Lingual 0.016
CuNiTi wires (G&H) were placed in both maxillary and
mandibular arches with open coil NiTi springs placed for his
UR2, LL1 and LR3. Bite turbos were also placed utilizing
Herculite for his LL4, LL3, LR3 and LR4. On April 25, the patient was seen
for his regular appointment and a bracket was placed on his UR2 (not in an
ideal position) and the open coil NiTi springs were activated for his LL1 and
LR3 (Fig. 4). Lingual 0.016 CuNiTi wires were replaced in both maxillary and
mandibular arches. On June 24, the bracket for his UR2 was repositioned to a
more ideal position and the lower bite turbos were removed as his bite had
opened significantly (Fig. 5). Lingual 0.016 CuNiTi wires were replaced in both
maxillary and mandibular arches.
On July 28, the patient began the SureSmile process. His upper and lower
arch wires were removed and the Innovation-L bracket doors were closed. Upper
and lower incisal manicuring was performed to give balance and symmetry to his
incisal edges. An i-CAT-SureSmile scan (8cm height at 0.2 voxel setting) was then
taken with a wax bite with the condyle seated in the glenoid fossa and leaving the
patient's bite open 3mm. Because of the amalgam restorations present in his
upper right and upper left posterior quadrants, and the root canal in his lower
right posterior quadrant, a supplemental SureSmile ora-scan was also necessary
for these three quadrants due to concerns with scatter with the i-CAT. Lingual
0.016 CuNiTi wires were replaced in both maxillary and mandibular arches (Fig.
6). On August 8, the patient's SureSmile plan was completed and his wires were
ordered to be bent utilizing SureSmile's proprietary software and robots (Fig. 7).
On September 14, 0.016x0.022 SureSmile CuNiTi wires were inserted in
both maxillary and mandibular arches. Clear plastic buttons were bonded on his
UR3, UL3, LL3 and LL3 and 3/16in, 3.5oz vertical elastics were given to the
patient to be worn at nighttime. On November 7, the patient returned and
photos were taken (Fig. 8). 0.017x0.025 SureSmile CuNiTi wires were inserted
in both maxillary and mandibular arches. The same vertical elastics were continued
at nighttime only.
On January 5, 2010, photos were taken again to track treatment progress and
virtual wire bends were ordered using SureSmile's proprietary software to address
some minor tooth alignment issues (Figs. 9-11). The plastic buttons were
removed and vertical elastics were discontinued. On January 26, the patient
returned to have his .017x0.025 SureSmile CuNiTi finishing wires inserted. On
March 9, the patient returned to have his Innovation-L lingual fixed appliances
debonded and moved him into retention with an Essix ACE retainer with full-time
wear and a L3-3 fixed lingual splint. On July 27, the patient returned for
final records, and retention wear of his Essix ACE retainer was reduced to nighttime
only (Figs. 12-14).
Summary and Conclusions
Total treatment time for this patient was 12.5 months. Total number of
appointments from the initial bonding appointment to the debond appointment
was 10, including one emergency appointment. I am truly amazed at the efficiencies
of these phenomenal technologies of Innovation-L, SureSmile QT, and i-
CAT and the fact that I can give my patients a completely aesthetic option for
treatment in a significantly decreased treatment time.
I currently have approximately 75 SureSmile QT cases that are in treatment.
Approximately two-thirds of my cases are in treatment with SureSmile QT in the
upper arch and SureSmile for labial in the lower arch and approximately one-third
of my cases are in treatment with SureSmile QT for both arches. I personally feel
that SureSmile QT will be a great option for all of our patients, especially for
those patients looking for a truly aesthetic option for orthodontic treatment and
want to have their treatment completed in a shorter treatment time. Are there still
lingual issues with SureSmile, such as inter-bracket distance? Absolutely.
However, so far I have been impressed and what I do know is that technology
only keeps getting better.
Internationally recognized speaker, Dr. Ed Lin, is a full-time
practicing orthodontist and partner at both
Orthodontic Specialists of Green Bay (OSGB), in Green Bay, Wisconsin,
and also Apple Creek Orthodontics (ACO) in Appleton, Wisconsin.
Dr Lin received both his dental and orthodontic degrees from
Northwestern University Dental School ('95 - DDS and '99 - MS).