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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. 9 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 10 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. 11 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. 12 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. 13 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. 14 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. 15