Journal of Orthodontics, Vol.

40, 2013, S27-S33

LINGUAL
SUPPLEMENT
Lingual orthodontic treatment: what is
the current evidence base?
Angela Auluck
Dental Rooms, London, UK

As the number of adults that seek orthodontic treatment continues to grow, so too is the popularity of lingual fixed appliances.
Although the aesthetic advantages associated with these systems are obvious, for some orthodontists, there has been a
reluctance to offer lingual-based treatment to their patients. This is often based upon the perceived problems associated with
lingual braces, relating to discomfort and difficulties with speech for the patient, and problems in using these appliances for the
orthodontist. Although some of these factors have been investigated, the current evidence base is weak, possibly due to the fact
that these are evolving appliance systems. Among the studies that have been carried out to date, pain and discomfort for the
patient appears to be similar following the placement of labial or lingual appliances, although the onset can be earlier with
lingual brackets and the location different, with the tongue more frequently being involved. Customized lingual brackets may
be associated with less pain than pre-fabricated. In addition, patients do seem to be more likely to experience difficulties with
speech and mastication when fitted with a lingual appliance. However, there is some evidence that the lingual surfaces of the
teeth are more resistant to early demineralization and caries. Little data exist regarding treatment outcome and ease of use for
the orthodontist, either between lingual or labial appliances or between different lingual systems. Further research is required
to investigate the efficiency of lingual appliance systems, both for the patient and orthodontist.

Key words: Lingual orthodontics, evidence base, patient experience, risks and benefits, treatment outcomes

Received 8 February 2013: accepted 8 June 2013

Introduction that approximately 10% of British Orthodontic Society

Over the past two decades, the demographics of patients
receiving orthodontic treatment has changed from
predominantly children to a marked increase in the
number of adults. In part, the advent of aesthetic
appliances has influenced this increase in the acceptability
of orthodontic care for adults.' Currently, the ultimate
aesthetic appliance that provides full three-dimensional
control of tooth movement is the lingual appliance.^
Assessments of attractiveness and acceptability asso-
ciated with orthodontic appliances have shown that a
significant number of adults requiring treatment refuse it
on the basis of the negative appearance associated with
many commonly used appliances.^ Indeed, a number of
patients are willing to fund treatment with appliances
they deem more aesthetic"* and in the hierarchy of
attractiveness; lingual appliances are rated the highest.^
Although the use of lingual orthodontics has progres-
sively increased on a global scale^ uptake in the UK has
been slower. There are approximately 950 specialist
orthodontists in the UK and of those, approximately
26% treat adult patients.^ However, in a recent study, of
all orthodontists surveyed, only 0.3% were routinely
using lingual appliances.^ This is surprising, considering
members are also members of the British Lingual
Orthodontic Society. So why are more orthodontists in
the UK not using lingual appliances? Clearly, limited
resources and a service that is in large part state-funded
are important factors, but a lack of availability for this
type of treatment within state funding cannot be the sole
reason. The lingual appliance is often considered less
practical for the patient because of discomfort and
irritation to the tongue, speech difficulties and poor
control of oral hygiene. Moreover, for the orthodontist,
problems with appliance manufacture, mechanics and
clinical outcome are also thought to be factors. As a
technique that has undergone a resurgence in relative
popularity over the last few years, it is perhaps timely to
review some of the evidence associated with the use of
these appliance systems. This paper will address the
current evidence base associated with the use of lingual
appliances (Table 1), in particular, highlighting areas of
research which require further investigation.
Patient experience
A positive patient experience is key to successful
orthodontic treatment. Although the use of lingual

Address for correspondence: A. Auluck, Dental Rooms,

1 Ridgway, SWI9 4RS London, UK.
Email: angela@dentalrooms.co.uk
2013 British Orthodontic Society DOI 10.1179/1465313313Y.0000000073
I- S28 Auluck Lingual Suppement JO September 2013

Table 1 Overview of current research associated with lingual appliance systems.

PATIENT EXPERIENCE
Discomfort '
Caniklioglu and Ozturk (2005)' Non-randomized comparative stucy
Wu ei o/. (2008)" Case-controlled prospective longitndinal study (age-matched)
Speech
Khattabe(a/. (2013)'" Randomized controlled trial ;
Hohoff eio/. (2003)'^ Non-comparative prospective stud^
Hohoff ei a/. (2003)" Case-control longitudinal study
Shalish et al (2012)" Comparative clinical trial

Eating -
Wue(/. (2011)" Prospective longitudinal study ^
Artun (1987)^ Retrospective cohort study
Weichmann et al (2008)'^ Prospective cohort study

Aesthetics and acceptability

Fritz et al (2002)" Retrospective survey
Cooper-Kazaz et al. (2013)^" Prospective case-controlled study

RISKS AND BENEFITS

Oral hygiene and caries incidence
Sinclair et al (1986)^' Case series :
Ruiken et al. (1986)" Prospective longitudinal study J
Bjarnason and Grondahl (1996)^* Cross-sectional observational stucfy
van der Veen et al (2010)" Randomized controlled trial "

Periodontal effects
Miethke and Brauner (2007)^ Case-control study
Demling et al. (2009)" Case-control study '
-
TREATMENT OUTCOME
Customized versus prefabricated brackets
Wiechmann et al (2003)" Case report
Grauer and ProfTit (2011)" ; Laboratory-based study

Direct versus indirect bonding

Schpack et al (2007)"^ Laboratory based study

Conventional versus self-ligating

Dallessandri et al (2012)^ Randomized controlled trial ^

appliances has been strongly associated with patient
discomfort and dysfunction, the available evidence
should be carefully considered.
Discomfort associated with lingual appRances
Pain and discomfort from conventional orthodontic
appliances is a well-recognized phenomenon,^ but it is
generally perceived that the pain experienced from
lingual appliances is of greater intensity and lasts
longer.'" A few studies have now been undertaken that
have attempted to determine pain and discomfort
experiences between patients treated with labial and
lingual appliances.''" According to these studies, the
pain experienced by patients immediately after the
placement of a lingual or labial orthodontic appliance
is broadly similar, and gradually disappears during a
one month period.'" However, marked differences in the
location of the pain do seem to- occur, with perhaps not
surprisingly, tongue soreness bdng higher in association
with lingual appliances.' This is most likely to be a
result of the restricted functional space of the tongue
after the placement of lingual brackets.
The influence of malocclusion on the amount of
discomfort experienced by patients with lingual appli-
ance has also been investigated. Interestingly, it was
 JO September 2013 Lingual Supplement
found that SNA and SNB were good predictors for the
level of tongue space restriction, the smaller the angles,
the more prone the patients were to experiencing
discomfort.'^
In addition to the location of pain, the onset does seem
to occur a little earlier (within 3 h) in patients with
lingual appliances, although no differences in the use
of analgesics has been identified between groups."
Customized lingual bracket bodies have a lower
profile than pre-fabricated brackets, which can improve
patient experience, with less tongue constriction and
rubbing. Subjective differences in oral comfort, speech,
mastication and oral hygiene have been investigated
between patients with pre-fabricated and customized
lingual brackets. Although all patients experienced
discomfort and functional difficulties, these were present
to a lesser extent in the customized bracket group.'^
The research to date allows clinicians to educate their
patients when making treatment choices and to fully
prepare them at the beginning of treatment. However,
future research is required to determine the conse-
quences of lingual and buccal discomfort and how this
may potentially infiuence patient treatment with lingual
and labial appliances. The infiuence of arch size and
shape, vertical skeletal characteristics and tongue-
associated parameters on the amount of discomfort
and dysfunction that might be expected should also be
investigated, as well as the influences of sex and age.
Speech problems associated with lingual appliances
One problem that lingual appliances do pose for the
patient is potential speech dysfunction. Lingual bracket
placement results in a substantial, although temporary,
change in the lingual morphology of the dentition. In
particular, the articulation zone behind the incisors is
altered, resulting in changed articulation, especially the's'
sound. It has been shown that both lingual and labial
apphances cause some speech disturbance, but there is a
higher degree of impairment in the presence of lingual
brackets.''' Studies using sonography to evaluate speech
performance, have shown that there is a true deteriora-
tion in articulation, even up to 3 months after the
placement of any lingual appliance, although with lower
profile customized brackets, this impairment in sound
performance can be significantly reduced in comparison
to pre-fabricated brackets.'^''^
Speech variation is an important consideration for
many patients considering lingual appliances because of
the impact that this may have on their quality of life.'^''^
As a result, it is imperative that the clinician advises
the patient of this very real potential side effect as part
of the informed consent process. Further prospective
Evidence-based lingual orthodontics S29
long-term evaluation of speech performance and an
international comparison is required, together with a
comparison on the effects of different lingual systems on
speech.
Eating with lingual appliances
Problems associated with eating can be seen with any
type of fixed orthodontic apphance, especially with firm
or fibrous food.'"'" However, masticatory disturbances
caused by lingual brackets may be worse than those
originating from visible labial brackets and this can lead
to social embarrassment." Brackets that are position-
ed against the tongue are known to cause more difficulty
in chewing^" and there is some evidence that lingual
appliances can take the patient longer to recover from and
adapt to, following placement,^" with an absence of
normal masticatory function still present at 4 weeks post-
placement.''* Indeed, one of the first randomized con-
trolled trials to compare oral impairments between labial
and lingual appliances has demonstrated more significant
masticatory problems associated with lingual brackets
immediately after placement."* Among lingual appliances,
lower levels of discomfort during eating have been re-
ported in association with customized lingual brackets.'^
Aesthetics and acceptability
Aesthetic orthodontic appliances have increased the
acceptability of orthodontic care for those who have
concerns over the appearance of apphances.' Although
previously, many adults did not wear braces, due to
perceived embarrassment,^ the number of adults seeking
treatment is increasing and the proportion of child to
adult patients is clearly changing. As a result, the more
aesthetic treatment options of lingual and clear aligner
appliances are gaining popularity.^''^^
While lingual appliances do seem to be associated with
the greatest oral dysfunction,'^ these drawbacks are not
necessarily a primary consideration for some patients
when choosing an appliance. Females under the age of 40
are still likely to choose lingual appliances and cite
aesthetic and professional considerations as a reason.'^'^^
Interestingly, a recent study has analysed the personality
traits and psychological features of adults in association
with appliance selection and in turn, their adjustability
to the appliance.^* It was found that patients with somati-
zation symptoms (distress arising from the perception of
bodily dysfunction) and obsessive-compulsive traits
(unwanted thoughts, impulses or reactions that are
unremitting and irresistible) were those that favoured
lingual appliances as their first choice. The common
factor in these two states is anxiety and those patients
 S30 Auluck Lingual Supplement
who were anxious or had bodily concerns opted for
the lingual appliance. As part of the same research, it was
shown that patients with reduced self-esteem experienced
more pain with any type of orthodontic appliance. The
overall conclusion was that actual selection of the lingual
appliance governed a patient's adaptability, with very
little effect from their psychological features.^''
The adaptation period associated with both lingual and
labial appliances is approximately the same, between 0
and 30 days;' however, some patients never seem to
recover and adapt fully to their lingual appliance. Despite
this, no significant difference in satisfaction between
patients treated with labial or lingual appliances or their
readiness to recommend treatment to other patients
have been reported, suggesting that customized lingual
appliances are as acceptable as labial appliances.
Moreover, these ratings of satisfaction improved over
time, most likely due to the improving alignment of the
teeth.''
Therefore, a number of features should be considered
when assessing whether a lingual appliance is suitable
for a particular patient and also whether expectations of
their adjustability to the appliance are realistic. It would
also be useful to look at personality types as an indicator
of tolerance to the discomfort experienced by patients.
Furthermore, validated psychological questionnaires
should be developed for patients who are considering
lingual treatment. This would help the patient to decide
whether lingual appliances are suitable and also provide
the clinician with a useful prediction tool.'^
Risks and benefits
There are a ntimber of well-documented potential
detrimental effects associated with labial fixed appliances,
which include early demineralization and caries, gingivitis
and periodontal problems, and root rsorption. How-
ever, only limited research has been carried out in relation
to these effects with respect to lingual appliances.
Oral hygiene and caries incidence
The maintenance of an excellent standard of oral
hygiene is imperative for the prevention of caries during
orthodontic treatment.^^ Previous studies have shown
no significant differences in the achievement of proper
oral hygiene between patients with lingual and labial
appliances.'''^' However, both lingual and labial groups
do experience an impact on oral hygiene, highlighting
the need for special oral hygiene instructions and
motivation of oral self-care during orthodontic treat-
ment, irrespective of appliance."
JO September 2013
Despite clinicians' attempts to control and maintain
patient oral hygiene standards during orthodontic
treatment, high caries incidence rates are considered a
risk with fixed appliances.'^^'^^ The main reason is plaque
acctimulation, especially in poorly accessible areas
around the bracket base, underneath the archwires and
between the gingiva and bracket. However, the lingual
surfaces of the teeth appear to be less prone to caries
than the buccal surfaces,^^ which is most likely due to
differences in surface morphology, plaque retention,
salivary flow and the mechanical cleaning of surfaces by
the tongue.^* Therefore, a seemingly clear advantage of
lingual appliances is that the lingual tooth surface is less
prone to demineralization and caries in comparison to
the corresponding labial surface in contact with a labial
appliance. Indeed, van der Veen et al.^'^ have investi-
gated this theory in a split-mouth study in patients aged
between 12 and 18 years randomly allocated to lingual
or labial appliances. The results showed that the buccal
surfaces are almost flve times more likely to decay than
the lingual surfaces during orthodontic treatment. This
study used a fully customized lingual appliance with
bracket bases that covered almost the entire lingual
aspect of the teeth. Whether the low caries incidence was
due to the almost complete seal of the lingual surfaces or
whether it was attributable to other aetiological factors
is unknown. How the effect of different lingual
appliance systems, bracket designs and different popula-
tions may influence decalciflcation is not known.
However, if these effects are universal, then lingual
appliances could arguably be considered not only for
aesthetic reasons, but also for the less harmful potential
effects on dental health. It is also worth noting that if
early demineralization or white spot lesions do occur
with a lingual appliance, they are obviously less notice-
able than those associated with the labial tooth surface.
Periodontal effects
The lingual surfaces of the teeth can be very difficult to
clean when fitted with a fixed appliance.'"' Orthodontic
appliances promote plaque-associated gingivitis, causing
gingival enlargement, an increase in periodontal probing
depths and bleeding on probing.^' This means that
lingual appliances might have the potential to induce
increased plaque accumulation and gingival inflamma-
tion restricted to lingual sites.^^ In addition, changes in
the microflora have been reported following the bonding
of a lingual appliance, with a higher prevalence of
periodontal pathogens such as Aggregatibacter actino-
mycetemcomitans?^ Therefore, maintenance of low
plaque levels is equally important during lingual ortho-
dontic therapy in order to maximize periodontal health.
 JO September 2013 Lingual Supplement
The research in this field is currently limited and it is
clear that further studies are required to investigate the
effects of a variety of lingual appliances on microbial
and clinical parameters with large sample sizes. In
addition, the effectiveness of strategies to prevent per-
iodontal disease, such as antimicrobial mouthwashes
and mechanical cleaning aides during lingual therapy,
also needs to be researched. This will allow clinicians to
recommend suitable cleaning aides and recommended
intervals of hygiene visits for patients undergoing fixed
lingual orthodontic therapy.
Treatment outcome with lingual
appliances
A high standard of treatment outcome is important for
the success of any orthodontic therapy. Although
therapeutic outcomes have been shown to be the same
with labial and lingual appliances,^'' there are some
important issues that need to be considered when using
lingual appliances.
Customized versus pre-fabricated brackets
Pre-fabricated lingual brackets have standard shaped
bases and therefore need a composite base to fix them in
their correct and individualized position. The advantage
of using these brackets is the concomitant use of straight
wires. However, it has been suggested that the use of
pre-fabricated brackets can lead to a number of clinical
difficulties, such as a high bond failure rate, time-
consuming finishing processes and increased patient
discomfort.^^ The popularity of customized lingual
brackets has increased over recent years and they seem
to have addressed many of the problems and clinical
issues that orthodontists were experiencing with pre-
fabricated appliances.^^ Several steps have been taken to
address the high bond failure rate of lingual brackets.
Firstly, greater bond strengths are being achieved by
extending the bracket base. Not only does this increase
the bonding area but also if a bracket needs to be
rebonded there is a positive lock between the tooth and
the bracket base.^^
The problems associated with finishing have also
been addressed by more accurate bracket positioning,
archwire fabrication and a reduction in torque play
between bracket slot and archwire. Indeed, planned and
end-of-treatment tooth positions using a fully custo-
mized lingual appliance have been compared using
computer software. These appliances were accurate in
achieving most of the goals planned at the initial set-up,
except for the full amount of planned expansion and
inclination at the second molars.^^
Evidence-based lingual orthodontics S31
Accuracy of direct versus indirect bonding
Regardless of appliance, an inaccurately placed bracket
can result in deviation of tooth position, reflected by
inappropriate rotation, tipping, in/out, extrusion/intru-
sion and torque.^^ There are a number of factors which
can contribute to inaccurate bracket placement in lingual
orthodontics, such as the limited access and visibility for
the orthodontist, shorter lingual crown heights, wide
range of labio-lingual crown thicknesses, sloped lingual
surfaces and tongue interference.^' However, in recent
years, technical advances have solved many of the
problems associated with accurate bracket positioning
for lingual appliances. Lingual brackets can be bonded
either directly usually using jig systems, or indirectly.""
Indirect bonding has often been advocated as the
preferred method of bonding lingual brackets,'"'''^
although bracket position is seemingly more accurate
with direct as opposed to indirect bonding.'*''
Conventional and self-ligating lingual appliances
A more recent innovation in the field of lingual
orthodontics is the concept of self-hgation. Dallessandri
et al.^ have investigated conventional and a customiz-
ed self-ligating lingual appliances in vitro using typo-
donts and an in vivo with a randomized controlled
trial. There is now some evidence that lingual self-
ligation may help to reduce the chairside time taken
for archwire changes and that the time saved is
potentially more significant than that saved using a labial
appliance. This study also highlighted that archwire
changes could be carried out more efficiently with self-
ligating lingual appliances, even by clinicians who were
not experienced with lingual appliances in general,
when compared with a conventional customized lingual
appliance.
Further research is required to more accurately
compare treatment outcomes between these two types
of lingual appliance. The mechanics associated with
these appliances vary not only due to the ligation
method, but also because of the orientation of the slots
in the brackets, the inter-bracket spans and the reduced
frictional resistance. All of these factors will ultimately
affect final treatment outcome.
Conclusions
Although the concept of lingual orthodontics is not a
new one, interest in this technique has varied over the
years due to perceived (and real) problems associated
with it. Early research was mainly based on comparisons
with labial orthodontics in terms of patient experience
 S32 Auluck Lingual Supplement
and final treatment outcome. However, in more recent
years, lingual orthodontics has established itself as a
viable treatment option in its own right research has
started to move towards comparisons of different
lingual appliance systems themselves, particularly the
efficiency of mechanics and validation of technical
aspects associated with appliance manufacture.
Further research is required in the form of randomized
controlled trials to investigate the efficiency of treat-
ment, patient experiences and the risk-benefits of this
treatment modality. Currently, there is little or no
research input in this area of orthodontics in the UK, a
situation that will hopefully change in the near future.
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