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The 3M Incognito Appliance System J. Clifton Alexander, DDS, MS

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I have used the Incognito* Lingual Appliance System since its introduction in North America in 2003. I had been phasing out traditional lingual orthodontic appliances and using clear aligner therapy throughout the three years prior to being introduced to Incognito braces. When the Incognito System was presented to me, it was clear it would address many of my frustrations with both traditional lingual appliances and aligners. Traditional lingual appliances are bulky and cause significant tongue irritation and speech issues for many patients. Finishing with them is also an issue for most orthodontists, and we often convert to clear labial appliances or a positioner for a quality finish. When I began phasing into aligners I had great success early on, but became overconfident and attempted to do too much with the appliance. With aligner therapy limitations, the Incognito System had perfect timing. It is a significantly smaller appliance that greatly improves patient comfort and speech, and the technology behind the 100 percent customized system allows me to treat cases, from start to finish, with the same high quality that I expect from my labial appliance. I can't say that for the traditional lingual appliance and aligner therapy. The following is a selection of the top five principles of my introductory course called "The 10 Principles of the Incognito Appliance System."

Principle #1: "If It's Good for Labial It's Good for Lingual"
This means that we finally have a 100-percent customized, invisible appliance that can treat to the same high standards as our labial appliances. This has not been true in the past with traditional lingual or aligner therapy. It also means that any auxiliary appliance that the orthodontist may utilize with his labial appliance, he can use with the Incognito System. Whether it's as simple as elastics, TPA, headgear and lip bumper, or more advanced as Forsus Appliances, TADs or Herbst Appliances, the Incognito System can support them all. It's just a matter of proper treatment planning and communication with the lab.

Principle #2: "Use Customized Appliances to Deliver Individual Treatment Goals"
The technology behind the lab work is unsurpassed. Of course any high quality appliance begins with high quality impressions, so PVS impressions and a simple lab form is all that is needed to start the process. Once the lab receives these, they reset the malocclusion into an ideal occlusion based on the doctor's individual treatment plan, whether it involves non-extraction, extraction, orthognathic surgery or other. When the doctor approves the individual setup, the case is sent to manufacturing. It is a system of customized brackets that are designed with CAD/CAM technology for each individual tooth for each arch. The technician focuses on making each bracket as small as possible for patient comfort, as well as including as much of the lingual surface of the tooth as possible. This is important for two main reasons. First is bond strength, greater surface area gives greater strength. Second is accurate rebonding should a bracket come off. In the past, the prescription was delivered by a custom pad of composite between the generic bracket and tooth. Incognito brackets fit flush to the tooth capturing all of the lingual anatomy so that if the bracket does come off, it is easily rebonded in ideal position thus maintaining the prescription of the appliance and eliminating wire bending during finishing. This virtual image of the brackets is then sent to a special "printer" that prints something like a wax pattern of each bracket, which is then cast in gold. The next part of the system is archwire fabrication. The CAD/CAM software designs the individual archform based on the bracket position on the ideal setup. This same archform is used from the initial archwire to the final archwire and is different for each arch of every single patient. By using an ideal archform from the very beginning to end, it makes the appliance a very efficient system. This virtual archform is then sent to a robot that bends as little of an archwire as an .012 superelastic NiTi to as large as an .018 x .025 Stainless Steel.


Principle #4: "Follow Recommended Clinical Procedures"
After the case is delivered back to the orthodontist's office, it's time to bond the brackets on the patient's teeth. This is done with an indirect bonding technique. There are options available for either light cure or chemical cure. Both come with very specific recommended conditioners and adhesives that are common in most offices. There has been much research and design with the most effective bonding procedures and we can bond these brackets to any surface whether it is enamel, gold, porcelain, amalgam or even dentin. The most successful doctors follow these recommended materials and procedures to great detail and rarely have bonding issues. Of course there is also a recommended debonding procedure with special pliers that makes debonding simple and easy as well.


Principle #5: "Commit to Proper Ligation for Full Engagement and Control Early in Treatment"
Just as with our labial techniques, ligation is important to make sure the customized archwire is fully engaged in the slots of the brackets to realize the ideal occlusion. It is very important that this engagement is realized early in treatment so that the initial and intermediate archwires set up the stiff, full-size archwires. If the archwires are not fully engaged at the end of treatment, the ideal set up will not be realized. There are two or three ligation techniques that, while unique to the Incognito System, are very effective and simple to perform with little experience.


Principle #8: "Use Extraction Treatment when Necessary"
While most of us attempt to treat cases without extractions, depending on selective diagnostic criteria, we all still have cases that should be treated with extractions. In non-extraction cases the mechanics are very similar to our labial technique. Simply unravel the crowding or close the spaces, then coordinate the arches using whatever auxiliaries and timing necessary to achieve a nice Class I occlusion. In extraction treatment plans however, spaces are closed only with sliding mechanics, not closing loops. It is typically en masse retraction of the anterior six teeth in first bi-extractions, and anterior eight teeth if 5s are extracted. An important aspect of this type of space closure is not to have any bends in the wire from the mesial of the extraction space all the way to the most posterior tooth. This is to prevent any binding of the wire in the slots, as the wire slides through the posterior teeth. Powerchains are typically used and TADs are always a good option when anchorage control is a concern.


Conclusion
The Incognito Appliance System has been a wonderful addition to the practice and has tapped into a completely new market of patients looking for a totally invisible and competent way to straighten their teeth. I am no longer limited to certain types of cases to treat with an aesthetic appliance, but rather can do anything with lingual that I can do with labial. The cases shown here are examples of that. My very first case that was a simple Class I and was initially interested in aligner therapy; the second case is of a more moderate nature, had significant space closure where we used extraction mechanics; and the third, a very difficult orthognathic case that was treated in 19 months.


Case #1
Diagnosis: Class I malocclusion, moderate crowding, moderate deep bite, anterior segments significantly retroclined
Treatment Plan: Align, level and open the anterior bite, use elastics as necessary to coordinate the arches
Comments: While she was an excellent patient, the treatment time of 14 months was a little longer than what my labial appliance would have taken me. However, when starting something brand new, I always plan on it taking longer. I was pleased with the results and felt confident that the result was much better than what I could have gotten with aligner therapy because of the control of a fixed appliance.


Case #2
Diagnosis: Class I malocclusion, moderate spacing of the maxillary arch, severe maxillary protrusion and deep bite
Treatment Plan: Level arches and retract maxillary incisors using extraction, sliding mechanics with maximum anchorage
Figures 5a-5h: Case #2 start photos
Figures 6a-6d: HG band and Cervical HG
Figures 7a-7f: Before and after laser gingivectomy
Figures 8a-8h: Case #2 finish
Comments: The patient chose extra-oral anchorage with a cervical headgear over TADs. He also wore Class II elastics during space closure and was an excellent cooperator with both. Due to the amount of maxillary anterior retraction and relative intrusion the gingiva hypertrophied so a laser gingivectomy was performed near the end of treatment.


Case #3
Diagnosis: Class III skeletal/dental, tripod occlusion on the incisal edges and third molars, severe dentoalveolar expansion of the mandibular arch due to enlarged tongue. Significant medical history was a pituitary gland tumor and resulting onset of acromegaly that contributed to the jaw growth and expansion.
Treatment plan: Pre-orthodontic glossectomy followed four months later with the Incognito Appliance System to narrow and constrict the mandibular arch prior to orthognathic surgery for a mandibular setback and three-piece maxillary expansion.
Comments: This was a good example of the importance of communication between the oral surgeon (Dr. Larry Wolford, Dallas, Texas), myself and the lab in order to get the coordinated result. The surgical and orthodontic treatment plan was carefully communicated so that the lab setup accurately predicted the surgical outcome. Once the setup was completed, and the archwire sequence was carefully followed, the result was predictable. In addition to the lingual appliances, a lower labial bar was also used to aggressively constrict the mandibular posterior width and was used for two and a half years post treatment as an additional retention appliance. Long-term retention includes maxillary and mandibular wrap around Hawleys to control arch width as well as mandibular fixed 3-3 retainer.












Author’s Bio
Dr. Cliff Alexander grew up in Dallas, Texas, and graduated from Highland Park High School. After receiving his BBA degree from St. Edwards in Austin, he moved to Santa Barbara, California to join a consulting firm. While there, he began to see the business side of dentistry as many of his clients were in the dental field. He realized that dentistry could satisfy his goals in business as well as his first objective of being of service to the people. So he decided to go back to school with the goal of entering dental school, and then of being accepted to orthodontic residency. He graduated from Baylor College of Dentistry in 1993 and from St. Louis Department of Orthodontics in 1996. He was asked to join the part-time faculty in St. Louis in 2000 where he lectures on the Alexander Discipline and oversees orthodontic patient care once a month.





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