Lingual You Will Love - Dentsply-GAC

Lingual You Will Love
Capturing the Incremental Patient
with Invisible Orthodontics
A White Paper Report
By: Dr. Ronald Roncone
Contents
Dr. R. Roncone Biography . . . . . . . . . . . . . . . . . . . . . . .1
The History of Lingual Self-Ligating Brackets . . . . . . . . 2
What’s Available Today?. . . . . . . . . . . . . . . . . . . . . . .3-5
Case Selection Criteria . . . . . . . . . . . . . . . . . . . . . . . 6-11
Do’s & Don’ts of In-Ovation L MTM . . . . . . . . . . . . . . . . 12
Bracket Placement & Wire Selection . . . . . . . . . . . 13-26
Case Studies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27-42
Materials Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
Dr. Ronald Roncone Biography
After receiving his undergraduate degree from Marquette
University, Dr. Roncone pursued graduate study in physiology
and neuroanatomy at the Marquette School of Medicine while
simultaneously earning his dental degree from the same university.
His CV includes postdoctoral certificates from the Harvard School
of Dental Medicine and the Forsyth Dental Center.
Dr. Roncone’s practice in San Diego County, California, specializes in adult treatment
(aesthetics, surgical and TMD) as well as “early” treatment for children. He is a respected
and frequent lecturer, having taught more than 500 seminars around the globe. His
impressive list of technical innovations include long (8-12 week) intervals between
patient appointments, which he introduced in 1989 through the use of titanium wires,
and the development of a unique prescription for bands and brackets. He is widely
known in the orthodontic community as the “Guru of Marketing.”
Lingual You Will Love
By: Dr. Ronald M. Roncone
Lingual Orthodontics are not new in the
world of Orthodontics. Crude attempts at
lingual orthodontics were tried many years
ago. The first true lingual began almost
simultaneously about 1980 with Dr. Kurz of
California and Dr. Fujita of Japan. Patients
around the world were hungry for an
appliance which would give them straight
teeth but could not be seen. Because of the
potential commercial windfall various
companies entered the market place. In the
United
States
many
orthodontists
immediately jumped into this new area only
to realize that working with braces on the
inside of teeth was not nearly as easy as it
was when attached to the outside surfaces
of teeth. Due to the steep learning curve,
the general acceptance of braces by U.S.
citizens and the improvement in clear
braces; lingual orthodontics, with a few
notable exceptions disappeared. Meanwhile,
those orthodontists outside of the U.S.
worked on mastering lingual and making
slow steady improvements to the various
techniques.
All of these statements have some element
of truth in them, yet all can be refuted.
This paper will attempt to address all of
these statements. However, even if they
could not be totally refuted, one overriding
factor remains:
Patients want “invisible” orthodontics!!
For many years the most used bracket in
lingual orthodontics was the Kurz bracket
(Ormco). It was a solid, well conceived
bracket which went through seven
generations. The bracket remains basically
the same as it was almost twenty years ago.
Other lingual brackets have been
developed over the years, but most of the
“improvements” have come in the area of
precision placement of the brackets.
Doctors Takemoto, Scuzzo, Fillion, Wiechmann
and others have made significant
contributions in this area.
Several years ago the biggest leap in
development was the size of brackets
conceived by Drs. Takemoto and Scuzzo.
The bracket was very small and targeted the
anterior teeth commonly referred to as The
“Social Six”. Interest is again building for
use of the lingual bracket as part of the
orthodontist’s offerings to their patients
due to the high demand for an invisible
solution.
Some common observations arose from the
initial experience with lingual orthodontics.
• Lingual orthodontic treatment
takes longer.
• Results of lingual treatment are
not as good as labial treatment.
• Lingual treatment is too hard on
the orthodontist because of poor
postural positions required.
• Patients do not speak well with
lingual braces.
• Tongue irritations are a constant
problem for lingual patients.
• Patient visits take substantially
longer with lingual braces.
• The time required to master
lingual treatment is not worth the
effort.
• It is too difficult to tie-in archwires.
Yet with all the improvements, lingual
orthodontics remained difficult. For the
patient, speech problems could be
overcome, but it was not a quick or easy
adjustment. Patients also took a long time
getting used to the tongue irritations.
Gingival hyperplasia was also a common
problem.
2
Even when the orthodontist mastered the
“mechanics” of lingual, it was still difficult to
ligate the wire to the brackets. Wire tying
stainless steel ligatures to each bracket or
using special-ties such as the “double over”
tie were very time consuming and difficult.
With these thoughts in mind the next stage
of lingual treatment necessarily led to
lingual self-ligation. Several years ago, in
conjunction with GAC, we began the
development of the In-Ovation “L”. It is
currently in use in many areas of the world.
The bracket is small: 1.5mm in thickness and
2.2mm in width. The clip is very easily
opened and closed which eliminates the
difficult and time consuming task of wire
tying or placing elastomeric modules. The
same basic philosophy of light wire
treatment that is part of the In-Ovation “R”
and “C” protocol can be used on the
lingual. With all of these advancements in
technology, the highest degree of quality
still requires indirect procedures for full
lingual. Many excellent methods of indirect
are currently available.
As an offshoot of this self-ligating bracket
(SLB) it is very easy to treat simple cases
requiring no basic changes in occlusion with
In-Ovation “LMTM” (L=Lingual, MTM=Minor
Tooth Movement). Mild to moderate
crowding of the anterior teeth can easily be
treated in a matter of weeks. All of the cases
that our office has treated have been
completed within the 6 week to 4 ½ month
period. Most of these are under 10 weeks.
In-Ovation LMTM utilizes a reduced base size
and is designed to address these simple
cosmetic cases. The reduced base allows
the clinician to place the bracket near the
incisal/occlusal edges of teeth thereby
eliminating any gingival irritation problems.
It allows clinicians to correct minor
misalignments with minimal office and
chairtime incorporating only a simple round
wire treatment.
Figure 3: In-Ovation
“LMTM” closed
Figure 1: In-Ovation “L” closed
Figure 5: In-Ovation
“LMTM”back view
Figure 2: In-Ovation “L” opened
3
Figure 4: In-Ovation
“LMTM” side view
Figure 6: In-Ovation
“LMTM” opened clip
Almost every day, a mother or father of a
patient expresses their desire to have
straight teeth but they do not want to show
braces and they don’t want it to take very
long. Some of these patients had braces
years ago and did not continue to wear
retainers and subsequently developed
crowding of the anterior teeth. Most of
these people have good to excellent
posterior occlusions.
In my opinion the use of LMTM has many
advantages over retainers and aligners:
• Truly invisible.
• Very tiny (1.5mm thick) virtually eliminates
tongue irritation.
• Minimal speech problems.
• They are not dependent on patient cooperation
(other than proper brushing).
• Since they are placed near the incisal/occlusal
edges of teeth, there is little gingival problem.
Others never had braces but have
continued to get crowding of teeth over the
years. In the past I would attempt to correct
these problems with retainers. The problem
was that most people did not wear these
retainers enough to obtain the results
desired. Their treatment would continue on
for many months. This was frustrating both
for the patient and me. The treatment also
became a financial disadvantage.
• They can be placed directly; therefore no
laboratory fees are involved. For those who
routinely do their own indirect bonding you can
continue the process if you so desire.
• Chair time is very minimal at each appointment.
There are no “re-ties”. The light round wire
continues to align teeth if left alone.
• 80% of patients require only one wire.
• The clips open easily and close easily with the
tool provided, or with an explorer (my choice).
While clear aligners have become popular
this was not the answer for me because of
the excessive amount of time it takes at the
computer planning for relatively simple
treatment. In addition the expense of the
aligners was also a concern that ultimately
led me to look for a better solution
• Depending on country, province or state laws,
placement and removal of archwires is easily a
task that can be delegated to auxiliaries.
Figure 7: In-Ovation “LMTM” series closed to opened
choose a compromise result if their current
malocclusion is not worsened.
Certainly not all those who desire LMTM
treatment are good candidates. Case
selection is important. LMTM is meant as a
cosmetic alternative only. Those patients
whose correction requires root torque or
uprighting are not good candidates.
However, those who desire alignment only
who might obtain “better” treatment if full
bonded appliances were placed may still
They must understand the unstable nature
of the result and agree to lifetime retention.
These patients should be fully informed of
the limitations of such treatment and sign a
potential risk and liability disclosure form
(shown next page).
4
LMTM Cosmetic Orthodontics
_____ It has been fully explained to me that the orthodontic treatment I have agreed to
is cosmetic in nature only.
_____ LMTM (Lingual Minor Tooth Movement) will be a short duration only (8 weeks to 5
months) depending on the amount of crowding involved.
_____ Appointments will be from three (3) to six (6) week intervals. Due to the rapid
nature of tooth movement, a strict schedule must be adhered to. If a scheduled
appointment is missed it may be necessary to reschedule at a time which may be
inconvenient in order to maintain proper control of tooth movement.
_____ Wear on anterior (front teeth) can place the thicker part of those teeth in a
position which does not look perfectly aligned. As an alternative, your family dentist
may restore the worn teeth either before or after the orthodontics.
_____ Since roots may not be positioned precisely as is possible with full braces, it will
be necessary to wear lifetime retainer(s). These may either be of the removable, or the
fixed type. In most cases, the fixed or non-removable type will be recommended.
Signed _____________________________ _____________________________
Patient/Responsible Party
Roncone Orthodontics
5
Cases
Compromise #1
Figure 8: Patient A
Patient A
•
•
•
•
•
Class I anterior open bite
Patient states she has been treated two times previously
Her tongue thrust has caused relapse both times
She is willing to “live with” the open bite
Wants upper incisors aligned
6
Compromise #2
Figure 9: Patient B
Patient B
•
•
•
•
Class II division 1 subdivision
Patient states she had four years of orthodontics as a
teenager
Does not want to go through full orthodontics again
Wants upper and lower anteriors aligned only
7
Ideal Case #1
Figure 10: Patient A
Patient A
•
•
Good Class I occlusion
Slight crowding upper and lower anteriors
8
Ideal Case #2
Figure 11: Patient B
Patient B
•
•
•
Class I occlusion
30 years post orthodontics
Crowding of lower anteriors
9
Ideal Cases #3
Figure 12: Patient C
Patient C
•
•
Class I lower crowding
Lower anteriors not touching upper anteriors
10
Ideal Case #4
Figure 13: Patient D
Patient D
•
•
•
Class I occlusion
Rotations upper anteriors
Crowding lower anteriors
11
The Do’s and Don’ts of LMTM Treatment
Do’s
•
•
•
•
•
•
•
•
•
•
•
Don’ts
•
Do…place brackets no more than
2mm from incisal edges of teeth.
Do…in most cases, bond brackets 44.
Do…make use of crimpable stops.
Do…use open coil (Sentalloy stopwound) springs where appropriate.
Do…use a straight .012 Sentalloy as
your first wire when you would like
to upright first bicuspids or rotate a
canine that has a distal lingual
rotation.
Do…use a “Mushroom” arch always
as your second (final) wire.
Do…see patients every 5-6 weeks.
Do…add some type of build up to
the occlusal of upper molars when
bonding maxillary teeth. This will
prevent lower incisors from biting
into the upper brackets.
Do…realize and have the patient
understand that this is cosmetic
only.
Do…always check with .001
Shimstock (with patient in the seated
position) to be sure there is no tooth
contact 3-3. Lingually inclined upper
anteriors or other cases of
overcoupling will lead to distal
displacement of the mandible and
TMD problems.
Depending on country, province or
state laws, placement and removal
of archwires is easily a task that can
be delegated to auxiliaries.
•
•
•
•
12
Don’t…even think about placing a
rectangular wire!!
Don’t…ever keep a straight .012
Sentalloy in place for more than 8
weeks…6 weeks is better
Don’t…engage a labially placed
tooth with the first archwire even
when it can easily be done
Don’t…place brackets on lower
crowded teeth when there is a deep,
tight overbite unless you bond upper
teeth also to move them forward
Don’t …use elastic chain – use elastic
thread instead
Bracket Placement – Direct
Figure 15: Placement of upper lingual bracket
Figure 14: Lingual instrument
(The common posterior
bracket placing instrument)
Figure 16: Placement of lower lingual bracket
Wire Selection
In order to produce a bracket that is very small, the slot size of LMTM is .018 x .025
The only wires used include the following:
•
•
•
•
.012 Sentalloy (straight)
.012 Sentalloy (mushroom)
.014 Sentalloy (mushroom)
.016 Resolve with lingual archform
Only 1 or 2 of the above wires are used on each patient.
13
.012 Sentalloy (straight)
Figure 17: .012 Sentalloy (straight)
012. Sentalloy (straight) placed for six weeks ideally and NEVER more than eight weeks.
Used only when:
 First premolars are tipped lingually and need to be moved labially
 Canines are rotated distolingually and need to be rotated into a more ideal
position
All of these patients (Patient A, B and
C) have a disto lingual rotation and
therefore are ideal candidates for a
straight .012 Sentalloy wire.
Figure 18: Patient A
Figure 19: Patient B
Figure 20: Patient C
14
.012 Sentalloy Mushroom
Figure 22: .012 Sentalloy Mushroom Arch
Figure 21: .012 Sentalloy Mushroom Arch
Usually used as an initial archwire (in most cases). In slightly crowded cases this may
be the only wire used.
.014 Sentalloy Mushroom
Figure 24: .014 Sentalloy Mushroom Arch
Figure 23: .014 Sentalloy Mushroom Arch
May be a first or second archwire
15
.016 Resolve
First bend in
mushroom arch
Figure 25: .016 Resolve
Figure 26: Bend into mushroom arch
This is a Beta-titanium wire which can be bent into a mushroom arch and additionally
have step up or step down bends placed in it. It can also be used with a closing loop
in space closure situations.
16
Figure 27: Closing loop
Figure 28: Helical loop (side view)
Figure 29: Helical loop
Open Coil Sentalloy Springs
Sentalloy stop wound open coil springs (GAC) are often used to open space
between crowded teeth so that brackets can be properly placed and/or to make
room so that wires can be properly engaged into brackets.
Figure 30: Sentalloy stop wound open coil spring
17
Crimpable Stops
Stops are often used to advance a wire so that teeth may be moved forward
when desired. The stops are secured to the wire by using a distal end cutting
plier and squeezing in 2 places on the stop.
Figure 31: Crimpable
Stops
Figure 32: Advancing wire
not engaged
Figure 34: Crimpable stops
18
Figure 33: Engaged
Potential Problems
1.) Overexpansion of premolars or canines
This occurs when a straight Sentalloy .012 is used for too long a period of time.
Ideally, a straight wire should be used for no more than 8 weeks and preferably 6
weeks.
Premolar Overexpansion
Figure 35: Initial (Patient A)
Figure 36: .012 Sentalloy (straight)-The day
braces were placed (Patient A)
Figure 37: 10 weeks later overexpansion of
premolar and placement of .012 mushroom
(Patient A)
Figure 38: Problem is fixed, day of removal
No other wire other than that placed in figure
37 was used. (Patient A)
Patient A
19
Canine Overexpansion
Figure 39: (Patient B)
Figure 40: .012 Sentalloy (straight)-the day
braces were placed (Patient B)
Figure 41: Overexpansion of canines–patient
missed an appointment because of
Mononucleosis, wire was in for 11 weeks.
.012 Sentalloy mushroom was placed.
(Patient B)
Figure 42: Correction 6 weeks later-the
the problem was easily corrected by
placement of .012 Sentalloy mushroom arch
(Patient B)
Patient B
20
2.) Aligning teeth with excessive wear in the lower anteriors next to teeth with little to no wear
This condition occurs rather frequently. If worn teeth are elevated so that incisal
edges match, a thicker part of the worn tooth will be next to the non-worn tooth.
Obviously, this will not appear to be perfect labio-lingually. A decision needs to
be made on whether to live with the imperfection(s) or to bond the incisal edges
of the worn teeth to the appropriate length before placement of the brackets.
Figure 43: Before
Figure 44: After
Placing brackets too far from the incisal edge
This results in discrepancies in the labial-lingual direction since the bracket is
placed on the incisor cingulum which is obviously thicker than the incisal area.
Closing Spaces
This is more difficult than correcting crowding. If spaces are small they can easily
be handled with small diameter elastic “thread” which is figure-eighted. Elastic
chain will overpower the light wires and because of the lack of occlusal wings
there would be difficulty anyway.
Figure 45: Thread (Patient A)
Figure 46: Thread (Patient B)
21
For larger spaces in which teeth need to be retracted, a tube should be placed on the first
molars and a .016 Resolve wire with closing loops must be placed.
Closing
loop
Figure 47: Closing loops
Figure 48: Closing loops on patient
Engaging brackets that are displaced labially to a significant degree
Remember that teeth want to move toward the wire. Eventually reciprocal forces would
align teeth, but it will take significantly longer. Don’t engage these teeth at the initial
appointment:
Figure 49: The day braces were placed. Lower
right central incisor not engaged
Figure 50: 5 weeks later. Lower right central
incisor engaged
22
Bonding only canine to canine
While appropriate in some circumstances, it is usually not advantageous. Bonding 4-4
gives more options than bonding 3-3. Stops can be used and open coil Sentalloy
springs can also be used more easily.
Figure 51: 4-4 push coil springs (Patient A)
Figure 52: 4-4 push coil springs (Patient B)
Sentalloy
open coil
Crimpable
stops
Figure 53: Crimpable stops and coil (Patient C)
23
Wire Pokes
Wires which are only slightly out of place can cause significant problems with the tongue. To
avoid these problems the ends of wires can be annealed so they are “dead soft”; bond 4-4
instead of 3-3 which allows for easier access to distal ends; use the Roncone Distal Bending
Plier. In some cases it is preferable to leave the wire long and over the occlusal surface of a
premolar rather than make multiple bends to place them lingual to the teeth. When using the
Distal Bending Plier, the wire does not need to be made “dead soft”.
Figure 54: Bend wire down
Figure 55: Bend wire down
Figure 56: Bend wire up
Figure 57: Bend wire up
Figure 58: Wire over occlusal
Figure 59: Bent 4-4 with Distal Bending Plier
24
Placing brackets on canines with a pronounced central cingulum
Teeth in this category cause a “rocking” or “rolling” problem when placed directly. To avoid
this, a composite build up on either side of the cingulum is performed in the mouth. This
provides a flat surface on which to place the LMTM bracket. Those offices using indirect with a
custom base do not obviously have this problem.The following example is shown on a model
but is done intraorally.
Figure 60: “Rocking”
Figure 61: Central cingulum is pronounced
Figure 62: Composite build up
Figure 63: Providing flat surface to place bracket
Retention
Because LMTM is a cosmetic only orthodontic procedure, stability can be a problem. Roots are
not aligned or torqued. Crowns are merely aligned and leveled. It is recommended that fixed
retention be used especially on the lower. The author’s preference is the use of dead soft .011
ligature wire folded back on it two times to provide three strands. These strands are squeezed
together and placed from canine to canine on the lower and if use on the upper the teeth
deemed appropriate by the orthodontist. These strands are burnished against the teeth. A
small amount of the bonding material of your choice is then placed over the wire on each tooth.
25
Figure 64: Ligature wire
Figure 65: Measure
Figure 66: Squeezed together
Figure 67: Three strands
Figure 68: Bonding
Figure 69: 3-3 bonded retainer (patient A)
Figure 70: 3-3 bonded retainer (patient B)
26
Typical LMTM Cases
1.) Class II division 1 subdivision left
2.) Patient had previous braces for 4 years
3.) Said she wore headgear 12 hours a day
4.) Only wanted alignment of upper and lower anteriors
Figure 71: Initial
Patient A
27
Occlusal bonding
with NeoBand Blue
Figure 72: The day LMTM braces were placed, .012 straight Sentalloy upper and
lower
Patient A
28
Figure 73: Placement of .012 Sentalloy mushroom
Patient A
29
Figure 74: The day braces were removed, upper 2-2 and lower 3-3 bonded retainer
Total treatment time 10 weeks
Patient A
30
1.) Class I crowding, deep overbite
2.) Patient wanted treatment of lower arch only
Figure 75: Initial
Patient B
31
Wire not
engaged
Figure 76: The day LMTM braces are placed .012 Sentalloy straight
Patient B
Open coil
(Sentalloy)
Figure 77: IPR mesial of lower right 4 and distal lower right 3, open coil spring
to shift midline right
Patient B
32
Figure 78: .016 Resolve bent into mushroom
Patient B
Figure 79: Day braces were removed, bonded lower 3-3 retainer placed.
11 weeks treatment time
Patient B
33
1.) Class I crowding
2.) Patient undergoing full mouth reconstruction with temporaries in place
3.) Lower lingual only
Figure 80: Initial
Patient C
34
Figure 81: .012 straight Sentalloy (Patient C)
Patient C
Figure 82: Full engagement .012 Sentalloy (Patient C)
Patient C
35
Crimpable stop
Crimpable stop
Figure 83: .014 Sentalloy mushroom, advancing stops mesial to lower canines
Patient C
Figure 84: Day of removal replacement of lower fixed canine to canine retainer
12 weeks treatment time
Patient C
36
1.) Class I crowding of lower anteriors
2.) Lingually inclined upper anteriors
3.) LMTM upper and lower
4.) Upper anteriors will be tipped forward to avoid overcoupling of anteriors and distal
displacement of the mandible
Figure 85: Initial
Patient D
37
Crimpable stop
Crimpable stop
Figure 86: Upper .012 straight Sentalloy, NeoBand Blue on occlusal of 6’s to avoid
lower anteriors biting into the brackets; Lower .012 straight Sentalloy, with advancing
stops, no engagement and labially displaced lower right central incisor
Patient D
38
Coil spring
Figure 87: Upper .016 Resolve Lingual archform bent into mushroom; Lower .014
Sentalloy mushroom with advancing stops and Sentalloy stop wound coil springs
Patient D
39
Same wire as
previous
appointment
Figure 88: Upper and Lower .016 Resolve Lingual archform bent into mushroom
Patient D
40
Figure 89: Upper Ace .040 clear retainer; lower fixed bonded 3-3 retainer.
Total treatment time 16 weeks
Patient D
41
There you have it. An invisible, easy, quick, highly delagatable, patient friendly, inexpensive
method which gives a large segment of potential patients exactly what they have wanted for
years.
In the minds of some orthodontists is one thought or question. The best or correct method of
treatment is full bonded orthodontics. If the patient does not want full treatment then I will not
do compromised aesthetic treatment. My question to those orthodontists would be, “If a
patient is best served by a combination orthodontics and orthognathic surgery, have you ever
done orthodontics only? If so, why did you compromise?”
What we must ask ourselves is can I make the patient happy without doing harm? If the answer
is yes then you should consider In-Ovation LMTM.
MATERIAL INDEX:
Reference #
90-511-90
90-611-90
90-751-00
02-511-80
02-911-101
02-911-102
02-911-103
02-911-104
02-911-601
02-911-602
02-911-603
02-911-604
Description
In-Ovation L MTM Upper 1,2,3
In-Ovation L MTM Lower 1,2,3,
In-Ovation L MTM Upper/Lower 4
Sentalloy 7” Straight Length Archwire
Sentalloy Lng 012 Upr Med Small
Sentalloy Lng 012 Upr Med Medium
Sentalloy Lng 012 Upr Med Large
Sentalloy Lng 012 Upr Med X Large
Sentalloy Lng 012 Lwr Med Small
Sentalloy Lng 012 Lwr Med Medium
Sentalloy Lng 012 Lwr Med Large
Sentalloy Lng 012 Lwr Med X Large
Pk10
Pk10
Pk10
Pk10
Pk10
Pk10
Pk10
Pk10
02-911-111
02-911-112
02-911-113
02-911-114
02-911-611
02-911-612
02-911-613
02-911-614
Sentalloy Lng 014 Upr Med Small
Sentalloy Lng 014 Upr Med Medium
Sentalloy Lng 014 Upr Med Large
Sentalloy Lng 014 Upr Med X Large
Sentalloy Lng 014 Lwr Med Small
Sentalloy Lng 014 Lwr Med Medium
Sentalloy Lng 014 Lwr Med Large
Sentalloy Lng 014 Lwr Med X Large
Pk10
Pk10
Pk10
Pk10
Pk10
Pk10
Pk10
Pk10
03-016-000
Resolve .016 Universal Arch Form
Pk10
47-601-22
52-800-01
Crimpable Split Stops
NeoBond Jr. adhesive kit
(includes Neo Band Blue Occlusal buildup)
Pk20
ODG88009
ODG400
10-000-08
47-505-53
ETM800S
Engage L lingual opening instrument
Roncone Bending Instrument set
Sentalloy Open Spg Med 150Gm
.011 Ligature Wire
Posterior Bracket placement instrument
42
Pk10
www.gacintl.com
© 2008 GAC International, LLC. All rights reserved. 4.2009-120-090-09