Download The Incognito™ Appliance System and Successful "Limited" Treatment

The Incognito™ Appliance System and
Successful “Limited” Treatment
by Dr. Adam Schulhof
Dr. Adam Schulhof
is a board-certified
orthodontic
specialist who
runs a state
of the art
private practice in Oradell, NJ. He’s a
co-founder of Kindersmiles, a practice
that specializes in the use of advanced
aesthetic technologies, such as the
Clarity™ SL and Incognito™ Appliance
Systems. More recently, he established
the Center for Cosmetic Orthodontics,
a practice that uses digital imaging,
advanced computer graphics and other
cutting edge technologies to provide
aesthetic and customized solutions for
his patients. Dr. Schulhof is a recognized
leader in the field of lingual orthodontics
and lectures frequently in the United
States and Internationally. He’s actively
involved in research and development
“It was the best of times, it was the worst of times, it was the age of
wisdom, it was the age of foolishness…it was the spring of hope,
it was the winter of despair…”
I’ve often marveled at how accurately the opening paragraph of Charles Dickens famous
tome describes the infancy of lingual orthodontics. Although those early years were fraught
with problems, the dedication of those early pioneers has given way to the Incognito™
Appliance System, the truly viable lingual orthodontic appliance system we use successfully
in our practice today.
Opening a new start up practice the day after leaving the motherly embrace of my
residency program, I was in for quite a shock. Perhaps I did spend too many hours
watching James Earl Jones tell Kevin Costner “people will come, Ray.” Who can blame
me? The voice of Darth Vader set to an orchestra, building in the background, it’s enough
to make anyone believe.
Realistically though, “If you build it they will come” does not a practice make. Fortunately,
I recognized the impact of emerging markets on our profession. It was clear that the adult
market was a force to contend with. The problem was that as a profession, we were illequipped to handle them. We needed better tools to satisfy their needs as well as ours.
Having treated a large number of patients with clear aligners, it was “clear” to me that in
a majority of cases they did not perform to our standards. And so, off I went on a journey
through the land of lingual. Within two years, and multiple appliance systems, it was
apparent that the Incognito Appliance System (at that time called iBraces™) stood head and
shoulders above the pack. Even in its infancy, the customization and phenomenal wire/slot
interface allowed for wonderful results (see Case 1).
continuing to improve and evolve lingual
orthodontics. Dr. Schulhof earned his
DMD degree from the University of
Medicine and Dentistry of New Jersey
and was inducted into the Omicron
Kappa Upsilon dental honors society.
He attended Columbia University for his
Orthodontic specialty training. Dr. Schulhof
is currently in the process of creating a
Lingual Orthodontic Program for many
universities in the United States.
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Case 1
1A
1B
1D
1C
1E
1F
Figure 1A-F: Our earliest Incognito™ (iBraces™) Appliance System case. Patient presented asking for Invisalign®. Due to the anterior crossbite and crowding, without a
tremendous amount of IPR, Invisalign could not achieve a good result. This case requires torque control and expansion. IPR to these small narrow incisors is contraindicated.
2A
2D
2B
2C
2E
2F
Figure 2A-F: Treatment with Incognito™ Appliance System took 8 months and patient was ecstatic. Notice the amazing torque control of the lower incisors. No IPR was performed.
Looking back, I will say with confidence that the Incognito™
Appliance System has been and continues to be a driving force in
my practice, setting us apart and helping to grow us beyond all
projections. It takes diligence, effort, practice, continuing education
and passion, all a small price to pay for giving patients what they
truly desire while satisfying our own high standard of care.
As the years went on it soon became apparent that within our typical
practice we had created another entity, an adult practice. A very wise
man once said, “with great power comes great responsibility” (OK so
it was Spiderman). Well I was finding out with a great adult practice,
comes… a whole new set of rules. One of the most blatant was the
need to acquiesce to – I’ll dare to say it – “limited treatment.”
We are changing lives…truly. It’s easy in the course of our busy
days and lives to forget this. Seeing so many adults on a daily basis,
though, puts it front and center. When a patient turns to you with tears
in their eyes to thank you, nothing beats that feeling. Adolescents
barely acknowledge how you’ve helped turn them from the awkward
duckling into a swan. An adult patient however, who’s felt for years a
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lack of confidence due to their smile, is a bird of a different feather.
There is no end to the difference we are making in their lives.
The one barrier to treatment with the Incognito System for some
patients is cost. Many adult patients can benefit from treatment
limited to the anterior six or eight teeth. The idea was to be able
to provide for these patients a less costly “limited” treatment, but
without the limitations we’ve had in the past from so called “limited
treatments.” In an effort to be able to provide that feeling to as many
patients as possible, I began using Incognito Braces in only a 3-3 or
4-4 setup rather than in a full arch configuration.
During my early forays into the land of lingual I had tried quite a few
social six and limited lingual systems. Unfortunately the results were
very…limited. These systems only allowed for two-dimensional
control. There was zero torque control and poor tip control. The cases
ended up similar to our clear aligner treatment. At the end we did
achieve an OK result (not perfect) but only after struggling and going
way over our predicted treatment time (see Case 2).
Case 2
3A
3B
3F
3C
3D
3G
3E
3H
Figure 3A-H: Patient requested diastema closure.
4A
4C
4B
4D
4E
Figure 4A-E: Initiated treatment with a two-dimensional social six system. It soon became apparent that although we were achieving space closure, the system provided limited
control. Notice the canine rollout on the lower left. It was necessary to add brackets for the bicuspids and to use auxiliaries on the labial.
5A
5F
5B
5C
5G
5D
5E
5H
Figure 5A-H: We achieved a satisfactory result at the cost of 13 months of treatment most of which was correcting “side effects” of tipping and rollout.
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Finishing Incognito™ Appliance System cases with extremely
accurate torque control lead to a natural train of thought. Using
Incognito fully customized brackets and archwires as a limited
treatment appliance can give us the perfect solution to adult
cosmetic treatment. We have full three-dimensional control.
The archwire is bent to each patient’s needs, and so we don’t have
to worry about canine or bicuspid “rollout” which is common in
two-dimensional products. We can now be confident to finish these
cases to our usual high standard of care.
Case Reports
Case 3
6A
6B
6F
6C
6D
6G
6E
6H
Figure 6A-H: Patients presents for correction of upper and lower anterior crowding. He has a beautifully socked in class I occlusion. Lower incisors need torque control.
7A
7C
7B
7D
7E
Figure 7A-E: We bonded the patient with Incognito™ Braces 3-3. Bonding appointment was 45 minutes. Lower .014 NiTi was engaged behind the self retaining wings.
This increases interbracket distance and levels very efficiently. The upper arch was engaged in the archwire slot with .014 NiTi.
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8A
8C
8B
8D
8E
Figure 8A-E: 4 weeks post bonding. The incisors leveled out so nicely we directly engaged the Upper and Lower .016×.022 NiTi in the slots to begin torque control.
9A
9C
9B
9D
9E
Figure 9A-E: Finishing up with an .0182×.0182 TMA for full slot filling torque control.
10A
10F
10B
10C
10G
10D
10E
10H
Figure 10A-H: Treatment was completed in 15 weeks. Notice the wonderful alignment, excellent torque control and retention of a perfect Class I molar and canine.
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Case 4
11A
11B
11F
11C
11D
11G
11E
11H
Figure 11A-H: Patient presents with Hx of previous ortho and 4 Bi Exo, complaining of crowded anterior and “tipping of my teeth to the left.”
12A
12C
12B
12D
12E
Figure 12A-E: Due to canine rotations we bonded Incognito™ Braces 4-4.
13A
13C
13B
13D
Figure 13A-E: We worked our way up to the .0182x.0182 TMA.
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13E
14A
14B
14F
14C
14D
14G
14E
14H
Figure 14A-H: Treatment was completed in 23 weeks. Patient was ecstatic and appreciated the “tip control” we achieved.
15A
15B
Figure 15A-B: Tip Control Comparison.
Incognito™ Braces 3-3 has been another boon for our office.
Even more impressive than the beautiful results is the minimal
chair time involved. The initial bonding appointment is so easy.
With the small anterior tray moisture control is simple. The entire
appointment can take as little as a half hour. Wire changes are
simple and quick. My assistants love it almost as much as the
patients do. Speech and discomfort are greatly minimized
compared to a mouthful of brackets and patients are acclimating
in two to three days or less. When we tell a patient their treatment
will take six months we mean it. There is no need for “reboots”
or multiple “finishing” appointments. This saves us an extreme
amount of aggravation and overhead. The patient’s experience is
extremely positive and we continue to turn out “raving fans.”
Most importantly we are providing our patients an amazing
service. We are addressing their chief complaint, doing it invisibly,
comfortably and easily while maintaining full control and treating to
amazing standards and results.
Case photos provided by Dr. Adam Schulhof.
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