Hello Alfredo, In my opinion, customized lingual brackets are a must to treat patients with lingual appliances, the result should be better, faster treatment and the patient will be able to see the endresult, before the beginning of treatment, If during treatment, the result is not as planned, re evaluation and finishings wires may be needed. There is limited scientific proff, that custom brackets and wires indeed will improve treatment result and reduce treatment time

Dear Hero, What do you think about the possibility of reducing the impact over TMJ and the surrounding tissues if we change the micro voltage produced by the bite plane over the neuromuscular system at the moment of biting?

Hello Alfredo, I am not an expert in TMJ problems, but in digital planning of orthodontic treatment and custom appliances. Maybe you should ask this question seperately.

Well, the matter is that at the hospital we have noticed that patients wearing lingual brackets modify their closing pattern (sometimes the TMJ problems tend to reduce or even to disappear), and I began to think that bite planes can be worthy to improve the neuromuscular status of masticatory muscles...

The lingual appliance will indeed function as a bite plate such as a bite turbo ar removable splint and will help to relax the musculature and prevent grinding.

This will surely be effective in some TMJ problems. However, all orthodontic treatment will change the occlusion. So, the use of splints bevore the start of orthodontic treatment as Roth mentioned, is not needed for most TMJ cases

I had seen that some adult patients with troubles on the TMJ ,when LB are bonded tend spontaneously to improve their situation. Have you noticed this?

i have experience of using cheap chinese lingual brackets which don't have customized lingual bases . if you use indirect bonding which is must with lingual orthodontics you can manage to proper adapt the bracket on lingual surface by varying composite thickness .The brackets are good for leveling and alignment ,good tip control but torque qualities are poor . You need wire bending for torque which is offcourse difficult on lingual side . i prefer to use GIC occlusal bite block during intial level and alignment instead of using brackets as block because of high failure rate of breakage if use so . personally i think they are not so hazardous for tmj . Patient adapt in a couple of weeks . Same effects can be found in labial brackets or aligners

I found these same problems of torque quality that you described, even with no so cheap brackets, and I improved this control with a robot I designed for wire bending. I'm still worry about having to pay the huge fees the companies charge for customizing lingual brackets, considering that with “traditional" appliances I'm able to obtain good results (and honesty, I dislike to leave treatment plan decisions on the hand of the lab technicians. I rather prefer to choose the final positions of the case designing the setup by myself...).

Dear Gilbert the problem with lingual system is that no study have been done from lingual side like the one done by Lawrence Andrew for labial side .Though every aspect remain same but it easy to give tip from lingual . But torque feature and prominence feature remains a problem . Many customized lingual bracket maker dont tell what what torque they have placed in the bracket . It more like a Lingual Base Customization .These systems are good skeletal class 1 . i agree with you that customized lingual system , clear path , aligners is like working in your office under supervision of lab technicians .

Our problem is that we use cook book formulas and we do orthodontics which commercial companies make us to do .

its a matter of time orthodontist will move back to Andrew concepts of keeping a large inventory of brackets and do Customization of brackets both in torque,prominence and counterrotation both for lingual and labial orthodontics .

The concept of using one magic bracket set for all cases should end whether its cost effective or not!

And even more...

I think, that we cannot keep going ignoring that it is a matter of fact that lingual appliances provoke (promoting?) changes under the neuromuscular system (sometimes those are desirable changes, ). In other words, I see the lingual technique as a physiological and very practical manner to obtain a better natural occlusion. The clue is to understand what the patient needs and how can we get them. By the way, at the Hospital we are starting a research protocol in order to obtain information about torque/tip characteristics of lingual brackets...

Best of luck for your research

Dear Dr. Gilbert

I really appreciate CAD/CAM customized appliances, but they are not vital to achieve good results. With high quality lingual brackets like STb and/ or InOvation L and an appropriate and realistic set-up, we can obtain the same or even better results. Regarding the effects on TMJ, I consider this an advantage of lingual orthodontics. I have a good casuistic of patients with TMJ problems in the beggining of treatment, and all of them improved their situation. I don't use an specific bite plane, but the upper anterior brackets act like it.

Congratulations on your discussion and research!

Dear proffesor Cal-Neto,

I have noticed the same improvement on the TMJ with the lingual appliances, but am the first time I know about a colleague who have had the same experience. By a chance have you documented/registered these cases? I would love to include your findings on the citations of my research.

The main problem cited here is the cost of customised lingual appliances. If the cost was less, one will not hesitate using customised lingual appliances. This statement itself suggests superiority of customised ove stock brackets. With recent advances in technology and decreasing cost, Printing cusomised brackets both lingual and labial from one CBCT scan is going to be common. In India the cost of customised lingual appliances at par with international brands have drastically come down from Lacs to thousands. Using Biteplane brackets will soon become obsolet as the customised brackets have many advantages

I agree with you about the convenience/advantages of the customizing of lingual (and labial) appliances. It seems even better if the cost of doing this is not so high. But I still think the bite plane is usefully. Why not customizing also the height of the bite plane?

Bite plane was inevitable and not compulsory part of actual lingual treatment. Now when one can do away with this not so required feature, it can be added thr' customised brackets in required cases only

This idea seems to me wise. Select the using or not using of the BP depending on the status of the TMJ and the neuromuscular system. This way the appliance will be really individualized for each and every patient. I got it. Thanks a lot.