A SIMPLE APPLIANCE FOR IMPROVING PATIENTS' COMFORT WITH THE LINGUAL APPLIANCE

Silvia Geron D.M.D., M.Sc

www.lingualnews.com Vol 4 No 1, Feb 2006

One of the main reasons for low acceptance of the Lingual techniques by patients and orthodontists is the discomfort to the patients at the beginning of treatment (1,2). All patients have some difficulties during the adaptation phase, which lasts about three weeks for 35% of them and more than three weeks for 36%. (3) 

1. Bonding only one arch at the time, the other arch should be bonded at least two months later.
2. Educating, preparing the patient for the difficulties, and reassuring him during the first weeks after bonding.
3. Using a protective periodontal pack (Barricaid) over the most irritating brackets,
4. Blocking the distal end of the wire with composite material
5. Avoiding bends and loops and using sliding mechanics for space closure.
6. Using a soft splint made from a 1.5mm-thick silicone material for night wear in open bite cases. 

Many parameters were examined as possible predictors for the amount of discomfort, like age, sex, malocclusion, overjet, overbite and psychological profile (4). None was able to predict which patients will be more sensitive than others to lingual appliances. (3,5).

The main problems the patients are confronted with are speech problem and tongue irritation. Tongue irritation is caused by the contact of the tongue with the lingual brackets and the tendency to run the tip of the tongue over the new brackets. Many times the patients see bracket impressions on both sides of the tongue when they wake up.

It has been suggested to improve patient comfort and overcome this problem in different ways (3):

Many efforts have been made to improve patients' comfort and speech problems with the lingual appliances. New brackets were designed with flatter profile, smoother surfaces and smaller hooks (Stealth - American Orthodontics, Forestadent 3D and 2D, STb -Ormco) New bonding techniques suggested flattened custom pads (TOP, STb), and archwire insertion as ribbon arch (Forestadent) or lying flat on the lingual tooth surface (Incognito) (6-7)

Despite these improvements lingual brackets still induce discomfort and dysfunction to some patients, unpredictably, some patients with flat brackets onded close to the tooth surface suffers more than others with the traditional Ormco Generation 7 brackets with the large hook, bonded with a thick custom Pad.

The adaptation period in my practice is about 4-7 days for most of the patients, with no matter which brackets I use (Ormco G7, STb, Evolution Lt). Special efforts are made to reduce tongue irritations immediately after bonding, and since the speech problem usually follows the tongue irritation, it can be significantly reduced if tongue irritation is avoided.

Fig.1

Fig. 2

Tongue irritation is avoided by using the following:
1. Elastic sleeves are routinely used over "naked" long wires (fig 1A)
2. Separating modules are used routinely on the premolar and molar brackets after bonding G7 brackets(fig 1B)
3. The patients are instructed to use sucking tablets usually used for sore throat, and come immediately for emergency appointment if they need.
4. If the patients comes for emergency appointment, the irritating hooks, brackets or wires are totally covered with flowable composite (fig 2)
5. Soft omnivac plate is delivered to the patient for night wear, since the unconscious pressure of the tongue during sleep may increase tongue sensitivity.

Fig. 3

The plate I use is the outer part of the bonding transfer tray (fig 3)). The bonding tray I use is composed of an inner layer made of resilient silicone material (Memosil 2, Kulzer) which covers only the brackets, and an outer thermoformed layer made of soft, 3mm thick soft mouth guard, which covers all the buccal tooth surfaces, as well as the lingual surfaces up to the area of tongue contact. After using the tray for bonding, the tray is separated and the outer soft thermoformed layer is delivered to the patient for night wear for the first days after bonding.

www.lingualnews.com
Adult and Lingual Orthodontics
EDITORS:
Dr. Silvia Geron D.M.D., M.Sc
Dr. Rafi Romano D.M.D., M.Sc
Dr. Pablo Echarri D.M.D., M.Sc