TECHNO BYTES

Customized brackets and archwires for lingual

orthodontic treatment
Dirk Wiechmann, DDS,a1 Volker Rummel, DDS,b Andrea Thalheim, DDS,c Jean-Stefane Simon, DDS,d and
Lital Wiechmann, DDSe
Bad Essen and Essen, Germany, and Marseille, France

After 20 months of clinical testing and more than 600 bonded arches, brief interim conclusions can be drawn
on treatment with a new lingual bracket system, one that differs fundamentally from conventional appliances
in both design and manufacture. The demand for maximum individuality is met by using state-of-the-art
computer-aided design/computer-aided manufacturing technology to fuse the 2 normally separate pro-
cesses of bracket fabrication and bracket positioning. Both the brackets and the pertinent archwires are
customized. Additional advantages of the system include direct and thus simplified rebonding in the event
of bracket loss, more precise finishing, and enhanced patient comfort. (Am J Orthod Dentofacial Orthop
2003;124:593-9)

F
ew aspects of dentistry have undergone as dra-
matic a boom in recent years as dental esthetics.
But in contrast to services provided by general
dentists, orthodontic therapy often extends over a long
period, so not only is the outcome of esthetic signifi-
cance to the patient, but also the course taken to achieve
that outcome. Patient interest in more esthetic ap-
proaches to malocclusion correction was expressed in
the mid-1980s in an increased demand for lingual
appliances. This demand still exists today, as demon-
strated by the development of growth in treatment with
removable, transparent appliances. Because adult treat-
ment in particular often involves bodily tooth move-
ments that are difficult to achieve with removable
appliances, the indication for this type of treatment is
limited.1 Moreover, this type of treatment can be
compromised by the indeterminate problem of compli-
ance. A better alternative, therefore, is a fixed appliance
whose lingual application makes it invisible to others: a
lingual appliance.2-4
Despite the demand for “invisible braces,” lingual
a
Visiting professor, Department of Orthodontics, University of Münster,
Münster, Germany; visiting professor, Department of Orthodontics, University
of Paris VII, Paris, France; private practice, Bad Essen, Germany.
b
Private practice, Dortmund, Germany.
c
Private practice, Bad Essen, Germany.
d
Private practice, Marseille, France; visiting professor, Department of Ortho-
dontics, University of Paris VII, Paris, France.
e
Private practice, Essen, Germany.
Reprint requests to: Dr Dirk Wiechmann, Lindenstrasse 44, D-49152 Bad
Essen, Germany; e-mail, Wiechmann@Lingualtechnik.de.
Submitted and accepted, August 2003.
1
Dirk Wiechmann is the owner of a company that fabricates custom lingual
brackets.
Copyright © 2003 by the American Association of Orthodontists.
0889-5406/2003/$30.00 ⫹ 0
doi:10.1067/j.ajodo.2003.08.008
orthodontics failed to catch on in the United States in
the mid-1980s, and it became less significant thereafter.
However, further developments at different levels, such
as laboratory-based bracket positioning, archwire fab-
rication, and indirect bonding, have led to a rise in the
number of lingually treated patients in Europe and
Asia.5-10 Yet, when measured against its potential, the
lingual technique is still clearly underrepresented in
these regions, compared with conventional appliances.
The main reason is that most orthodontists fail to offer
their patients a lingual appliance as an optional treat-
ment method. When colleagues with experience in this
technique are asked why they have ceased to use it, 3
explanations are commonly given: the bracket loss rate
is substantially higher than in labial cases, and the
indirect rebonding technique is complex and imprecise;
the finishing process is time-consuming, and the aver-
age quality falls far short of that of labial cases11,12; and
patients often have difficulty adapting to the appliance,
especially when undergoing lingual treatment in both
arches.13,14
Thanks to technological advances, a new course can
now be taken in the manufacture of a bracket-archwire
system. By replacing mass-produced, prefabricated ap-
pliances with customized brackets and archwires, the
once-crucial problems deriving from lingual orthodon-
tics can be solved.15,16 This article outlines the devel-
opment and production of an innovative, fully custom-
ized lingual bracket-archwire system and demonstrates
its efficiency with a brief case report.
A different approach
The problems traditionally associated with lingual
orthodontics cannot be solved with conventional man-
593
594 Wiechmann et al
Fig 1. Scanned surfaces are composed of differently
sized triangles (standard triangulation language, STL
surfaces). More homogeneous surface areas are repre-
sented by larger triangles, and less homogeneous sur-
face areas by smaller triangles. Minimum surface reso-
lution: 0.02mm.
ufacturing processes; instead, complete individualiza-
tion of all appliance components is needed. In the
approach presented here, the processes of bracket
fabrication and optimized positioning of the fabricated
brackets on the tooth, which are normally quite sepa-
rate, are fused into 1 unit. Individualization of the
bracket base, a process used in various laboratory
processes and always essential in the lingual technique,
takes place during fabrication of the single brackets17-
19; in other words, each tooth has its own customized
bracket, made with state-of-the-art computer-aided de-
sign/computer-aided manufacturing (CAD/CAM) soft-
ware coupled with high-end, rapid prototyping tech-
niques. The individual production stages are described
below.
The manufacturing process
The first step in the manufacturing process is to take
a standard 2-phase silicone impression. The casts pro-
duced from this impression are used to prepare a
customized target setup. Noncontact scanning of the
therapeutic setup is performed with a high-resolution
optical 3D scanner (GOM, Braunschweig, Germany).
As with human perception, the 3-dimensional (3D)
scanner must examine the model from various perspec-
tives to create a complete 3D representation. The
outcome is a compound surface consisting of many
thousands of minute triangles (standard triangulation
language, or STL surfaces) that can be turned, ob-
served, and processed on a computer with appropriate
design software (Fig 1). Before further processing, the
arch to be bonded is aligned optimally to the later slot
plane.
American Journal of Orthodontics and Dentofacial Orthopedics
November 2003
Fig 2. Digital setup with individually defined bracket
bases.
Fig 3. Conventional lingual bracket (left) and custom-
ized bracket.
In contrast to conventional lingual brackets, which
have standardized mesh bases, a customized “virtual”
base is generated on the lingual surfaces of each tooth
(Fig 2). Because of the extreme accuracy of the
available scan, with a resolution of at least 0.02 mm,
the bases are later positively locked with the teeth.20
The pad surfaces generated are large enough to provide
greater bond strength and exact form-fit properties. The
bracket base is 0.4 mm thick. The bracket bodies are
freely designed with appropriate design software. The
bracket body we use has an extremely low profile
compared with others (Fig 3), guaranteeing absolute
control over the tooth and making for a simplified
ligation procedure. The testing of various slot types has
shown a vertical slot with a vertical insertion direction
to be ideal (Fig 4). The archwire thus runs like a ribbon.
By using custom software, the bracket bodies are added
to the setup and the pad surfaces, and are arranged so
that the slots are aligned in the virtual archwire plane
(Fig 5). The vertical height, angulation, and torque are
thus preset; only optimal first-order (positioning thick-
ness) adaptation is performed manually by shifting and
turning.
High-end rapid prototyping machines are used to
convert the virtual bracket series into a wax analog and
then into a final product made of an exceptionally hard
American Journal of Orthodontics and Dentofacial Orthopedics Wiechmann et al 595
Volume 124, Number 5

Fig 4. A, State-of-the-art maxillary incisor bracket with vertical insertion direction. In this version,
ligating can be done with simple elastic module or with German overtie. Positioning software allows
optimum angulation of hook. Accessory occlusal hook is optional. B, First-generation premolar
bracket with horizontal insertion direction (left) and state-of-the-art premolar bracket with vertical
insertion direction (right).

Fig 5. A, Bracket bodies (blue) are loaded from bracket archive to dental arch fitted with individual
bases (yellow). Whereas second and third order are preset, bracket body can now be shifted and
turned in slot plane for optimal positioning. B, Bracket body and bracket base are then virtually
fused.

alloy with a high gold content (Fig 6). This material has
a Vickers hardness of 310 kg/mm2. Because of the
extended customized base, which permits clear-cut
positioning on the tooth, the brackets can be directly
bonded by the orthodontist. However, the more time-
saving option is indirect bonding with a 2-phase sili-
cone bonding tray21,22 (Fig 7). For this purpose, the
bracket bases are first treated with silane and then fixed
on the malocclusion model with a microscopically thin
plastic film. The bonding tray is made of an inner,
softer silicone (Exakt N, Bisico, Bielefeld, Germany)
and an outer, extremely hard silicone (Lutesil, Bisico).
The indirect bonding is thus no different from the
conventional procedure and can be carried out with
unfilled acrylic or fiberglass-reinforced glass ionomer
cement, at the orthodontist’s discretion.
As with straight-wire concepts, the archwire geom-
etry is yielded by the 3D location of the bracket slots.
Their exact position is known through the bracket
manufacture described above in 3D design software
and is transmitted to a bending robot through the export
of slot coordinate systems. This robot was a develop-
ment of the Orthomate system (Orametrix, Dallas,
Tex). It operates with 2 grasping tools and can bend
archwires precisely in highly complex geometries.
Superelastic archwires are thermally reprogrammed
during the actual bending process.15 This is the only
means of ensuring precision manufacturing.
Case report
A woman with pronounced crowding in both arches
came for treatment with a Class I occlusion on the left
and a Class II malocclusion on the right (Figs 8-10).
Lingual appliances were used because of the marked
decalcifications of the buccal surfaces. Teeth 14, 24, 35,
and 45 were extracted.
To resolve the maxillary anterior crowding, the
canines were moved to distal on .016 ⫻ .022 in
596 Wiechmann et al
Fig 6. A, In rapid prototyping, brackets are first produced in wax, applied in 0.02 mm layers. Red
support wax required for 3D production is removed thermally. B, Wax lingual brackets before
casting. C, Gold lingual brackets after casting.
Fig 7. Two-phase silicone bonding tray with precoated
lingual brackets.
nickel-titanium (Ni-Ti) archwire with power chains. To
prevent proclination of the incisors, they were initially
not ligated (Fig 8, B). The anterior segment was aligned
and the residual spaces closed with .016 ⫻.022 in steel
archwire (Fig 8, C). Intermaxillary elastics were used to
correct the distal bite on the right. The bracket bodies of
the maxillary left incisors were distally displaced on the
bases as a result of the initial crowding. Finishing was
done with a .017 ⫻ .025-in titanium-niobium archwire
(Fig 8, D). There was no need for additional correction
bends.
American Journal of Orthodontics and Dentofacial Orthopedics
November 2003
In the mandible, the first premolars were moved
distally on .016 ⫻ .022-in Ni-Ti archwire with power
chains (Fig 9, B). Due to the extreme crowding, only
the canines could be ligated initially. After complete
resolution of the anterior crowding, residual space
closure was executed with .016 ⫻ .022-in steel arch-
wire (Fig 9, C). Finishing was done with a slot-filling
.018 ⫻ .025-in Ni-Ti archwire. This dispenses with
additional correction bends in the finishing process (Fig
9, D). Total treatment time was 18 months. Figure 10
shows intraoral occlusion control.
DISCUSSION
This customized system addresses 3 problems tra-
ditionally associated with lingual brackets: the brackets
are more difficult to bond and tend to debond more
often, finishing is more difficult, and the brackets cause
speech problems or irritate the tongue in some patients.
Several steps have been taken to address the prob-
lem of difficult bonding and frequent debonding. First,
the bracket bases have been extended; this results in
greater bond strengths. Overall, the brackets have a
lower profile, which induces less leverage when biting
on appliance components (Fig 3). However, this alone
is no guarantee of a reduced bracket loss rate. The
quality of the impressions for the bonding model and of
the indirect bonding is still crucial.21,22 In addition,
attention is paid to avoiding any preliminary contact
American Journal of Orthodontics and Dentofacial Orthopedics Wiechmann et al 597
Volume 124, Number 5

Fig 8. Lingual orthodontic treatment with extractions, maxillary arch. A, Pretreatment. B, Maxillary
canines distalized with .016 ⫻ .022 in Ni-Ti archwire and power chains. To prevent proclination of
incisors, they are initially not ligated. C, After complete alignment of anterior segment, residual
spaces are closed with .016 ⫻.022 in steel archwire. Intermaxillary elastics correct distal bite on
right. Bracket bodies of maxillary left incisors are distally displaced on bases as result of initial
crowding. D, Finishing with .017 ⫻ .025 in titanium-niobium archwire. Additional correction bends
were not needed. E, Posttreatment.

Fig 9. Lingual orthodontic treatment with extractions, mandibular arch. A, Pretreatment. B,

Mandibular first premolars distalized with .016 ⫻ .022 in Ni-Ti archwire and power chains. Due to
extreme crowding, only canines were ligated. C, Crowding was resolved and spaces closed with
.016 ⫻ .022 in steel archwire. D, Finishing with a slot-filling .018 ⫻ .025 inch Ni-Ti archwire.
Additional correction bends were not needed. E, Posttreatment.
598 Wiechmann et al
Fig 10. Intraoral occlusion control.
with the dentition of the opposing arch when defining
the extent of the bracket bases and when subsequently
positioning the bracket bodies, especially in the buccal
region. If a bracket does need to be rebonded, the
form-fit properties between the bracket base and the
tooth provide a positive lock that makes incorrect
positioning unlikely. In addition, the direct placement
of brackets can be controlled by screen shots from the
manufacturing process in cases of less characteristic
tooth morphology, as observed especially in the man-
dibular incisor region. On completion of treatment, the
brackets should be removed with special debonding
pliers (Ormco, Glendora, Calif).
Three factors contribute to problems in the finishing
process: inaccurate bracket positioning, inaccurate
archwire fabrication, and inaccurate fit between brack-
ets and archwires (torque play). The virtual production
of the brackets on the computer almost completely
eliminates errors in the actual production of the bracket
bases. By using the extended bases (positive lock) and
the screen shots, positioning the brackets on the indi-
vidual teeth is relatively simple, with no great room for
error. Because all archwires are also produced with
CAD/CAM technology, this potential source of error is
of minor significance.12,23,24 An important step in
simplifying the finishing process is reducing the torque
play with nominally slot-filling archwires, because the
archwires tend to be smaller and the slots notably larger
than the given values. The resulting torque play might
lead in some cases to substantial finishing prob-
lems.11,16 If the appliance is positioned farther away
from the labial surface of the tooth in terms of an
increased positioning thickness, this problem is inten-
sified in almost direct proportion.11 In particular, incor-
rect torque can impact the second order in clinical
terms. Stamm et al,11 for instance, reported that a 10°
inaccuracy in torque results in an average vertical
American Journal of Orthodontics and Dentofacial Orthopedics
November 2003
deviation of 1.2 mm. This correlation is even more
pronounced in the buccal region due to the greater
positioning thickness. In Germany, the German Insti-
tute of Standards and Norms (DIN 13971-2) specifies
tolerances for bracket slots at between .0181 and .0197
in. The slot tolerance guaranteed by the manufacturer
for the new lingual bracket presented here is between
.0180 and .0183 in. Each bracket slot is measured on
completion of the production process (measuring in-
struments: Azurea, Belprahon, Switzerland). If a slot is
too small, it undergoes precision enlargement with a
broach tool; if it is too large, the bracket is refabricated.
As the clinical example shows, the finishing of a
lingual case can thus be performed with no additional
bends.
Some lingual orthodontic patients, especially those
being treated in both arches, have speech problems and
irritation of the tongue.13,14,25,26 However, the reduced
thickness of these brackets compared with traditional
lingual brackets has made this much less of a problem
(Fig 10). Prospectively designed studies evaluating
both subjective and objective perceptions are aimed at
shedding further light on this matter.27,28 The clinical
track record to date underlines the positive influence of
a lower-profile lingual appliance both on articulation
and on the extent of soft-tissue irritation.
CAD/CAM and rapid prototyping
After 20 months of clinical experience with the new
appliance and more than 600 bonded arches, we have
come to see the importance of a factor not previously
discussed: the appliance design can be readily opti-
mized at any time. In traditional manufacturing, retro-
modification involves the investment of major re-
sources; the production method presented here permits
any clinical shortcomings to be rectified immediately,
to the benefit of the very next patient. In addition, the
American Journal of Orthodontics and Dentofacial Orthopedics
Volume 124, Number 5
appliance can be tailored to both the existing maloc-
clusion and the preference of the orthodontist.
CONCLUSIONS
Custom bracket manufacturing provides new op-
portunities, especially in lingual orthodontics, by solv-
ing 3 of the most frequently cited drawbacks of lingual
appliances: difficult bonding and rebonding procedures
and more frequent accidental debonding, problematic
finishing processes, and patient discomfort.
The essential advantage of custom design and
manufacturing is the unlimited individuality of the
appliance. This seems to be the logical next step on the
path to a lingual treatment concept adapted to both the
patient and the orthodontist.
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