Lingual orthodontic education: An insight

INTRODUCTION

It is interesting to learn that Kinja Fujita introduced lingual orthodontics to his practice to prevent trauma from conventional labial attachments and accessories while performing martial art activities in Japan. He developed the Fujita Brackets with occlusal, horizontal, and vertical slots and practiced multibracket lingual technique using mushroom-shaped archwire.^[1-3] During the same era, Kurz worked on lingual orthodontics and developed Kurz lingual brackets. The Kurz lingual brackets, later on, evolved into seventh generation lingual brackets (Ormco) in 1990 and became popular worldwide.^[4]

Though lingual orthodontic technique was introduced in the 1970s and witnessed expansion in 1990s, its acceptance among orthodontists is poor despite the fact that lingual orthodontics offered truly invisible treatment modality for any malocclusion. In the United States, after initial period of euphoria, there followed a period of decline in its acceptance.^[5] This decline could be attributed to poor understanding of the technique, different biomechanics than labial, increased chair-side time, postural difficulties, poor laboratory facilities, and compromised clinical results. Thanks to the dedicated clinicians like Thomas Creekmore, Jim Wildman, Giuseppe Scuzzo, Didier Fillion, Pablo Echarri, and many others, the beginning of the 21^st century marked the resurgence of lingual orthodontics. Now, the clinical results achieved by lingual technique can be compared to the best of conventional labial techniques. But till today, the sense of rejection for lingual orthodontics is quite common among orthodontists. The number of orthodontists practicing lingual orthodontics is limited throughout the world in general. This is evident from the fact that the number of active members of the World Society of Lingual Orthodontics and European Society of Lingual Orthodontics, the two largest lingual societies in the world, is very limited compared to a number of orthodontists worldwide [Table 1].^[6,7] An introspection is needed to understand the reason behind this trend. Lingual technique differs from conventional labial orthodontics in all aspects including patient counseling. Unpredictable lingual surface requiring customization of the brackets and lingual biomechanics (especially loss of torque in the anterior teeth during retraction)^[8] are the main subjects of concern in finishing of a case. Increased chair-side time and operator’s postural problems are other issues for poor acceptance of lingual orthodontics by orthodontists. The lingual appliance causes more discomfort and speech distortion to the patient than labial appliances.^[9-11] Though it is more difficult to maintain oral hygiene with lingual appliances in place^[11] but the incidence of white spot lesions is reported to be decreased by WIN lingual appliance compared to conventional multibracket system.^[12]

Orthodontists, even today, rely on eloquence-based experts or a colleague’s advice, when faced with a clinical uncertainty, rather than follow an evidence-based practice to change their practice philosophy. This can be addressed by initiating programs and continuing education that will help with skill sets to have an in-depth understanding of the knowledge base available to us.^[13] Unfortunately, poor availability of evidence-based studies on lingual orthodontics is a matter of great concern. The number of clinical and research work relating to lingual orthodontics is less represented in literature. An online search in leading orthodontic journals could fetch very limited number of articles relating to lingual orthodontics [Table 2]. This trend is very unfortunate for the science because without independent research studies, there is every possibility that this science of invisible orthodontics would eventually be controlled and duly promoted to their advantage by companies who have a commercial interest in the field.

Is there a scope to improve the scenario? The issues like increased chair-side time and postural problems can improve only by vigorous clinical training because every individual goes through a learning curve to improve his skill. For example, the operator can do ligation of maxillary anterior teeth without bending his back or neck by an indirect vision from clinical photography mirror. However, ligating the arch wire through indirect vision needs practice. Similarly, the problems of bond failure or finishing and detailing can be taken care with a proper understanding of the subject and clinical practice. Experience will improve the accuracy of laboratory work and hence the end result.

Unfortunately, the exposure to lingual orthodontics is very limited in the regular postgraduate orthodontic curriculum worldwide. At present, the only way to learn lingual technique now is through short-term courses, part-time multi-module workshops, etc., Although these workshops help in orienting the orthodontist to lingual technique but they fail to offer comprehensive clinical training. Thus, the actual clinical learning curve begins with the orthodontist starting up lingual cases in his own setup. Mid-treatment complications, finishing, and detailing are reasons of worry as he has to find the solutions on his own. It is in this stage that many quit their journey citing poor treatment outcome. However, one should realize that it is unfair to judge the technique without expertizing the skill to perform. After all, we never had an opportunity to learn lingual technique as comprehensively as labial conventional orthodontics.

In contrary, the medical education system in different universities around the globe offers full-time super-specialization courses such as Doctor of Medicine, and Master of Chirugie (M.Ch.), after specialization in basic medical branches such as medicine, surgery, orthopedics, and ophthalmology. For example, in India, All India Institute of Medical Sciences offers three years super-specialization M.Ch. residency course in urology to the applicants who have completed their postgraduate specialization in general surgery (MS). The preamble of this course is quoted bellow.^[14]

“The objective of M.Ch. (Urology) degree course is to produce highly competent medical manpower in urology. The training ingredients should provide in-depth knowledge of the entire urology and relevant basic allied subjects. The course is expected to bring about a change in attitude toward better scientific approach with logic and analysis. More stress should be given to the development of psychomotor skills. This should culminate in shaping of a shrewd clinician, confident surgeon, and a knowledgeable teacher insured to basic research methodology. The basis of an ideal training program will be a powerful urology service complete in every sense…”

Thus, the main objective of super-specialization courses is to produce a highly competent medical manpower in a specialized area who is groomed to be a shrewd clinician and knowledgeable teacher. Both clinical and nonclinical research work carried out by the candidate during their course curriculum help immensely to expand the science.

Introducing a similar model of education (full-time super-specialty residency program) on lingual orthodontics will be a step forward. We have to understand the current scenario and challenges for the same. Few suggestions for true implementation will also be discussed in the following sections.

CURRENT SCENARIO

The regular orthodontic postgraduate curriculum offers very little clinical training in lingual technique. Most of the orthodontists worldwide depend on various lingual education programs as listed in Table 3. The company sponsored certificate training programs are usually for 1 or 2 days duration wherein the specific laboratory technique and bracket customization system are highlighted with supporting case reports (e.g., Incognito^™, Harmony, etc.). Though it delivers orientation toward a specific system but offers limited hands-on and no clinical training. These courses are useful for orthodontists who are already practicing lingual technique and now interested for the specific laboratory system for various reasons, but it offers very little to the beginners in contrary to the general belief.

Hands on training programs of 3–7 days have the advantage of a better understanding of laboratory procedures if it is demonstrated live. Workshops of longer duration, i.e. 7 days offer hands-on training for customization of brackets, transfer tray making, and clinical observation also. These workshops are helpful to the beginners to start simple nonextraction cases. But here, the drawback is a lack of comprehensive clinical training.

Another model of lingual education is part time residency extending over 1–2 years. The total course duration of the training program is covered in multiple modules designed months apart. For example, Hannover University, Germany offers M.Sc. course in lingual orthodontics, where study curriculum includes one introduction module, eight main modules, as well as writing master thesis with plea and oral exams.^[15] Similarly, Basel University, Switzerland runs a part-time master in the lingual orthodontic course of 2 years duration and eight modules.^[16] Thus, the students are privileged to have chair-side clinical observations or perform clinical procedures on the on-going lingual cases till their completion. Though presently this is the best model of lingual orthodontics education available, but it cannot be compared to full-time comprehensive residency programs.

CHALLENGES

As discussed earlier, lingual orthodontics is a completely different concept from the conventional labial technique. It needs dedicated clinical training and protocol. Unfortunately, in the present scenario, no institute or university offers full-time residency program. There is a shortage of faculties which can be a part of this education system. Limited available literature and study materials are also a concern. Furthermore, in recent years, the courses, education, and research are being increasingly sponsored and promoted by private companies with commercial interest. Thus, independent research and proper documentation are the need of the hour for this truly invisible orthodontic technique to flourish.

Despite these challenges, present decade has witnessed a rise in the popularity of lingual technique. Thanks to the determined clinicians and world leaders in this field for sharing their knowledge and work. If we think futuristic, there is a need to evolve lingual orthodontics into a super specialty branch for the orthodontists. Introducing a proper educational system is the need of the hour now. We have to move on in a very systematic realistic manner for the same.

A SUPER SPECIALTY PROGRAM

Orthodontics is credited as the oldest specialty of dentistry, thanks to the visionary Dr. Edward H. Angle. Soon after obtaining his dental degree in 1878, Angle became interested in “regulating” teeth. By 1886, he had achieved enough of a reputation to be appointed as the chairperson of the Orthodontic Department at the University of Minnesota (1886–1992). His address at the Ninth International Medical Congress in Washington, DC (1887), calling for the separation of orthodontics from dentistry, caused a reaction that marked the beginning of a life of controversy.^[17] He declared that “not until orthodontia is studied as a distinct branch in dentistry will it ever obtain success. There should be specialists in orthodontia and general practitioner should send to practitioner freely.”^[18] In the year 1900, he started the first school of orthodontia – The Angle school of orthodontia.

From then to now orthodontics has evolved into one of the most demanding postgraduate specialties in dentistry. Moreover, we are discussing history here to learn the course of evolution of our specialty-orthodontics and dentofacial orthopedics. We must realize that all the challenges that we discussed about lingual technique were also present during that era for conventional labial orthodontics. Hence, we need an optimistic approach for elevating lingual orthodontics to a super-specialty branch.

Full-time dedicated super-specialty residency program in lingual orthodontics will have the aim and objective to train orthodontists to acquire knowledge, skills, aptitude, and attitudes to be able to function as an independent clinician/consultant in lingual orthodontics and a teacher acquainted with research methodology. It may be suggested that M.Ch. in lingual orthodontics would be an appropriate degree to be awarded as the eligibility criteria for applicants would be after completion of Master in Dental Surgery in orthodontics. It will be practical and feasible to introduce this super specialty branch in the institutes and universities that have already running orthodontics postgraduation programs. In the beginning, 2 years duration of the course may look more feasible as we need teachers and guides for subsequent batches. Initially, visiting faculties would help to start the courses in universities/institutes where there is a shortage of teaching faculties, and online teaching (seminars and webinars) could be utilized. Once adequately trained manpower is available, full-time faculties can be recruited.

There is a country-to-country variation in the duration of educational systems for dentists and orthodontic specialists.^[19] Thus, it is important to discuss the duration of this program. The ideal duration of the lingual super specialty program should be at least 3 years. The first 6 months of the curriculum must include preclinical works such as customization of lingual brackets, transfer tray making, arch wire template making, and full complement of lingual treatment sequences performed in the metal typodont. During this period, the student should orient himself to lingual orthodontics by differentiating all aspects in comparison to labial conventional orthodontics. From the 3^rd month onward, clinical cases should be taken up for compiling the records and case discussion (diagnosis and treatment planning) so that immediately after 6 months he or she can start up the cases. Thus, the candidate has two and half years of comprehensive clinical training including finishing and detailing on lingual orthodontics. Minimum of thirty extraction cases should be addressed and completed by the candidate to complete the course. These 3 years of dedicated training in lingual orthodontics will complete the learning curve of an orthodontist. Eventually, at the end of this course, the chair-side time will reduce, proper posture with ligation by indirect vision would be attained, diagnostic and clinical skills will be sharpened, and laboratory dependency will be revert.

Apart from clinical training, compulsory original research work (both clinical and nonclinical) and preparation of the manuscript for publication must be included as a part of the curriculum. The topic of the thesis should be finalized within the first 6 months so that the candidate has sufficient time to work on it. Independent research work will not only help in learning research methodology but also strengthen the evidence-based database on lingual orthodontics. This will help in further refinement and evolution of the technique.

Syllabus for this program may include basic sciences such as head and neck anatomy, bone and muscle physiology, cellular biology, and genetics and the clinical portion of these programs include courses such as growth and development, biomechanics, biology of tooth movement, biostatistics, functional oral and dental anatomy, dentofacial orthopedics, multidisciplinary care, functional appliances, developmental biology, connective tissue biology, biomaterials, craniofacial anomalies, cephalometrics, TMJ and occlusion, functional considerations, and surgical orthodontics with special relevance to lingual orthodontics. Integrating of practice management in the curriculum will enable the clinician to excel in this field along with professional skills.^[20] Table 4 enlists the presently available books on lingual orthodontics. Seminars, case discussions, and journal presentations will help in establishing this branch. A candidate has to undergo theory; practical and viva voce exams with case presentations to be declared successfully completing the course. The course design is summarized in Table 5.

FINAL REMARKS

It is true that increased chair-side time, difficulty in working posture, and poor treatment outcome are the issues for rejection of lingual orthodontic technique by many orthodontists. But as with any specialty, learning curve takes its own time to master the technique and it is the most important phase for the orthodontist to either accept or reject lingual orthodontics. There are many short duration courses running worldwide to train orthodontists to take up lingual practice. These courses help in orientation and start-ups, but the real learning curve begins with the ongoing clinical cases, mid-treatment complications and their solutions. Lingual orthodontics is not about change in bracket system or mechanics. It is a completely different concept in all aspects. It differs from the labial technique in relation to patient counseling, treatment planning, anchorage considerations, applied dental anatomy, bracket system (positioning, bonding, rebonding, and debonding procedures), biomechanics, ergonomics, treatment duration, etc., Thus, it is not feasible in short duration courses or module-based part-time programs to acquire comprehensive training in lingual orthodontic education. Full-time residency program as discussed above is the future for this field. It will produce competent clinicians, teachers, and help in compiling the research database for the growth of this branch.

This goal can be achieved by a collective effort by the orthodontists, different orthodontic associations, universities, government regulatory bodies, and the lawmakers. Collective effort, systematic, and practical approach would help the cause in nurturing the first super specialty branch in dentistry:Lingual Orthodontics!