Lingual Orthodontics--Whither or Wither?
In spite of the fact that possibly 30% of practicing orthodontists have attempted to treat some cases from the lingual, the enthusiasm of most orthodontists for lingual orthodontics varies from guarded to nonexistent. While there is justification for "guarded", there is not for "nonexistent", because there is a certain amount of existing and potential demand in the marketplace for lingual orthodontic treatment, and in a capitalist society suppliers ignore demand at their peril.
It is to the credit of those who have been working and publishing on lingual orthodontics that they have not tried to gloss over the difficulties they have encountered. At the present time, lingual is more tiring physically, and requires more time and more patience. Some cases may have to be finished with a conventional labial appliance. There are periodontal considerations, restorative considerations, and anatomical considerations. It has been reported that lingual mechanics may produce unwanted results that are difficult to control such as anterior open bite and speech problems due to a restriction of tongue space. Downward and backward rotation of the mandible that accompanies the open bite tendency also tends toward a Class II molar relationship and taxing of anchorage. Class II correction has been found to be difficult with a lingual appliance. Lingual mechanics tend to expand the arches and to rotate molars mesiobuccally, which tend to exaggerate open bite and Class II tendencies. Finishing cases to high standards appears to be generally difficult.
Discretion limits entry into lingual treatment to the simplest Class I or mild Class II cases with good facial patterns, with spacing to consolidate or mild crowding that may require expansion. However, there are indications that with practice comes proficiency, and there is every expectation that excellent treatment results will be possible for most, if not all, malocclusions using a lingual approach.
It will require time and training to become proficient at lingual orthodontics. Perhaps this is a time to return to the typodont or manikin to practice the new approach. For treatment of patients, most practices and most patients will benefit from open-ended appointments in the beginning to allow for longer, less stressful visits. Practices most likely to succeed are those that are able to compress their patient care time and free up enough time to enable them to devote an extraordinary amount of it to learning lingual treatment. This includes not only practices that are efficient in scheduling, but also practices that have experienced a decline and would appear to be needing more patient starts to maintain a decent profitability. Many such practices are in affluent areas that have a lingual market.
In lingual orthodontics, orthodontists are looking at a marketing opportunity on the one hand, but also at a marketing responsibility on the other. The opportunity lies in that segment of the population that is aware of an orthodontic need, desirous of orthodontic treatment, able to afford it, but unwilling to have visible appliances. The responsibility lies simply in the endeavor of a business or a profession to satisfy the needs and wants of the public.
Properly handled, lingual orthodontics is a practice builder. When the orthodontist is ready, dentists in the community can be informed of the addition of this service and patients can be made aware of it through the practice newsletter and other internal means. In addition to adding lingual patients to the practice, the marketing of lingual also attracts others. Many patients who think they want lingual accept labial treatment when the pros and cons of lingual are explained, and many lingual patients become missionaries for the practice and refer not only other lingual patients, but labial patients as well. Indications are that a relatively small number of orthodontists are performing a significant amount of lingual treatment. From a marketing point of view, this means that the field is pretty much open to those willing to put forth the effort.
The trap of lingual is to offer the service before one has mastered the treatment mechanics required for the cases undertaken. A great deal of time and emotional energy can be wasted recovering cases that have gotten out of control. A great deal of credibility can be lost, even if all the potential problems and difficulties have been explained in advance. People forget. With all the warts, however, there seems little doubt that lingual orthodontics has the potential to be a positive influence in orthodontic practice. It would be a pity if it were to die on the vine through unwillingness of-orthodontists to master a new discipline.
Lingual orthodontics will probably turn out to be no more difficult or time-consuming than labial orthodontics. It is just a somewhat different bioengineering problem than we are accustomed to and one for which we have not yet developed a simple routine. Just because we have succeeded in doing that for the labial side does not mean we ought to expect instant equal results in a new modality.
Orthodontics cannot, should not, and will not stand still. Our entire history is dotted with creative solutions to clinical problems. The technical and mechanical difficulties of lingual treatment are bound to be overcome if we maintain our interest in it and do not close it down with a premature adverse judgment.
