Appreciating the art of custom surgical

orthodontic care
D1X XNeil M. WarshawskyD2X1X

Orthodontics has changed a lot since its humble beginnings. Today ortho-
dontics is not considered a luxury, but more likely a proactive attempt to cre-
ate better oral health through improving facial harmony and esthetics.
Occlusion and functional issues such as mastication, breathing, speech, and
self esteem are now issues that patients understand and want to improve.
Educational mechanisms such as the internet combined with a multidisci-
plinary team approach drive patients to ask for very specific treatment objec-
tives. However, there is a huge disparity in the variety of treatment
mechanisms that a patient may utilize. The choices presented to the patient
are often limited not by what the patient wants, but rather to mechanics
that the doctor uses daily. It is not reasonable to think that an adult will
want to have mechanics similar to what a growing 12 year old uses. Older
patients desire to hide their orthodontic mechanics, and thus the need for a
more cosmetic solutions was born. Isn’t it ironic that the most advanced and
accurate custom orthodontic appliance happens to be on the lingual of the
teeth?! This article will discuss and review how the Incognito appliance
system may be used to prepare cases for orthognathic surgery. The benefits
to this system are numerous. It’s effectiveness at setting cases up for orthog-
nathic surgery is real. Multiple multidisciplinary cases will be demonstrated
with issues in transverse, sagittal, and vertical planes. Cases will be shown
from treatment planning through retention. Historically, lingual orthodontics
has been perceived as a challenging concept to master. The Incognito appli-
ance system is uniquely different compared to labial mechanics as the arch
wire is a ribbon arch and as such it displays torque moves much more effec-
tively when it is planned and deployed. Properly utilized, the Incognito appli-
ance system can be the difference when teeth need to be decompensated
for surgery. It’s strength is delivering an accurate, predictable tooth position
while achieving esthetic excellence. Regardless of the dimension(s) to cor-
rect (transverse, vertical or antero-posterior dimension) via a combination of
comprehensive orthodontics and orthognathic surgery, lingual appliances
simply represent the best option when a patient demands esthetic applian-
ces to correct their malocclusion. (Semin Orthod 2018; 24:297–324) © 2018
Elsevier Inc. All rights reserved.

Introduction

University of Illinois Craniofacial Center Chicago, Illinois,

United States.
Correspondence to: Get It Straight Orthodontics, 3655 N Ashland
Ave., Chicago, Il 60613, United States. E-mail:
DrNeil@getitstraight.com
© 2018 Elsevier Inc. All rights reserved.
1073-8746/12/1801-$30.00/0
https://doi.org/10.1053/j.sodo.2018.08.006
1
Diplomate, American Board of orthodontics. Assistant Professor
of Surgery University of Illinois Craniofacial Center.
T he Incognito appliance system is a unique
concept relative to conventional orthodon-
tics. Several qualities define Incognito from all
other commercially available appliances. Differen-
ces include the orientation of the wire slot which
is ribbon in the anterior and edgewise in the pos-
terior and the fact that the brackets are reverse
engineered off the final target setup. Multiple cus-
tom adhesive choices allow variable strength

Seminars in Orthodontics, Vol 24, No 3, 2018: pp 297 324 297

298 Warshawsky
retention for the multitude of custom bracket
designs that can be created by Incognito. Unlike
tradition labial appliances that often enhance the
base of the bracket by welding mesh to the base of
the bracket to hold the adhesive tightly against
the base of the brackets, incognito brackets have a
smooth metal base. They garner retention by cov-
ering a large portion of the lingual surface of the
teeth. A study done in 2010 by Van der Vee, Attin,
and Wiechmann1 showed that white spot lesions
are 4.8 times more likely to occur on the labial
than on the lingual surface when using the Incog-
nito Appliance system. Furthermore they found
when using quantitative light-induced fluores-
cence (QLF) the increase in integrated light fluo-
rescence loss was 10.6 times higher buccally than
lingually. The results conclude that teeth are less
likely to be prone to carious activity when treated
from the lingual when acceptable hygiene is prac-
ticed. Furthermore by combining large unique
custom made bonding pads with a variety of cus-
tom composite solutions (these composite solu-
tions vary based on the substrate that the bracket
will be bonded to) the doctor can further custom-
ize the strength of the bond of the brackets
depending on what the doctor is trying to achieve.
These custom brackets bases intimately fit the sur-
face to be bonded resulting in an adhesive lock
that is quite resistant to strain. Having a smooth
base is however a mechanical disadvantage rela-
tive to a traditional labial bracket base with mesh
so to increase retention and resist breakage the
Incognito system gives the users many ways to
increase retention via custom construction. Some
of the more popular choices can utilize half occlu-
sal pads, custom molar bands (known as saddle
bands) for a firm hold. AP correction may be built
in through both utilization of both the Herbst and
the Forsus appliance system. Robotically bent arch
wires that can be created in different materials
make leveling even the most difficult cases possi-
ble. In 2011 a study by Grauer and Proffit2 evalu-
ated the effectiveness of the predicted outcomes
of 94 consecutive cases via dental casts from a sin-
gle practice over a broad range of malocclusions.
They were looking at whether or not the pre-
dicted outcomes were accurate or not. The study
showed that the fully customized lingual appli-
ance system, as described above, was accurate
within 1 mm or 4° of rotation of achieving the
intended goal. The study showed second molars
were not always accurate in expanding enough or
in achieving the final rotations. Overall occlusion
was overwhelmingly found to be accurate in
achieving its final target goal.
Last, but certainly not least, the ability to con-
firm that the brackets are being placed exactly in
the correct position (referred to as a clear preci-
sion tray) is a defining feature that separates Incog-
nito from all other appliance systems. Overall the
summation of all of these features help to define
Incognito as a unique custom manufactured ortho-
dontic appliance system. Yet, due to the nature of
its design, it alludes the use of the majority of the
orthodontic specialists practicing today. This prod-
uct requires a long-term commitment to master.
One must be committed to participating in various
forms of continuing education, a variety of custom
instrumentation to effectively manipulate the appli-
ance is recommended, and most importantly your
staff must accompany you on this journey, believ-
ing that this is the finest appliance available to treat
your patients. In short learning to utilize Incognito
on a daily basis is an ongoing long-term commit-
ment to learn to managing this appliance system
and it takes time. However, once it is learned, I
believe it will give you a competitive advantage to
offer patients a solution in a competitive market
where consumers are easily confused where ortho-
dontic services suddenly can be delivered without
an orthodontist (smile direct club, candid co
etc. . .) As technology continues to improve it
becomes a double-edged sword. An unstable econ-
omy along with tools such as software, pre pro-
grammed appliances, and clear aligners, attempt
to redefine the orthodontic market place where
patients push the boundaries of receiving care
without a doctor even being directly involved
hands on with patient care
One of the greatest misconceptions with the
Incognito appliance system is that it is a poor
choice to utilize when orthognathic surgery is
required to achieve the desired goal. Kairalla et
al.3 looked at the effectiveness of using lingual
appliances to prepare cases for surgery. Through
their article they demonstrated that esthetic lin-
gual appliances were able to be used to properly
prepare cases for orthognathic surgery.
This article will follow patients that demonstrate
severe malocclusions in the Transverse, Vertical,
and Sagittal planes. Cases will show treatment plan-
ning, presurgical preparation, surgical results, and
the final occlusion. Results will demonstrate that
cases were treated in a controlled, expedited
 Appreciating the art of custom surgical orthodontic care 299

manner. Patients will win as they will get a superior
result in an optimized manner. Although it is hard
to learn to use daily, Lingual appliances are the
ultimate cosmetic solution. Practitioners will win if
they master this concept. They will provide the best
care to patients while establishing themselves as a
leader among their peers. Patients will win as total
treatment time will require less visits to achieving
the end goal thereby more than justifying the digi-
tal planning and the cost of the custom appliance
fabrication.
Case 1
The first case to discuss is a patient who suffers
from Maxillary hypoplasia. Fig. 1A shows 2 separate
time points of the case. The left image is from sum-
mer 2013 and the photo on the right shows how
the underbite manifested into a complex crossbite
by the fall of 2016. A ceph analysis indicates that
the maxilla is retrognathic and must be advanced
relative to Pogonion to increase facial convexity
and overjet (Figs. 1B and 1C).
Our intended treatment plan was comprehen-
sive orthodontics augmented with an asymmetrical
2 Piece LeForte I osteotomy to achieve the dental
and skeletal correction for maxillary hypoplasia
without pushing the teeth up against the alveolar
housing. Being custom made, the Incognito appli-
ance may be built customized to your specific treat-
ment goals. In my office, the process begins with
an intraoral scan of the teeth using the 3 M Tru
Definition Scanner. I think the architecture that
3 M designed to store chair side oral scans is bril-
liant. From any internet connection I can quickly
determine where the digital work flow of a case is
at. Once the scan has been obtained we utilize the
3 M Treatment Management Portal, (TMP) soft-
ware the malocclusion STL data will be attached to
my custom order (Fig. 1D).
As I build my order, TMP will provide me a
pictorial image of what I am requesting so that I
may have a visual confirmation of what I am
requesting (Fig. 1E).
For surgical cases I tend to use bands on the
posterior teeth for 2 reasons. First the saddle

Figure 1A. Case 1 Unilateral crossbite due to Maxillary Hypoplasia.

Figure 1B. Initial Records of Case 1 indicating a complex malocclusion.

300 Warshawsky

Figure 1C. Cephalometric analysis of initial records Case 1.

Figure 1D. Incognito custom appliance RX.

 Appreciating the art of custom surgical orthodontic care
Figure 1E. Pictorial View of the Custom Build.
bands as we refer to them, do not necessarily
open the occlusion. They sit on the marginal
ridges of the teeth and extend down the buccal
and lingual contours of the molars for retention.
Unlike conventional bands, they do not go inter-
proximally between the teeth. In addition, you
may customize the casting of the bands with
labial ligation lug/cleat to create purchase points
to tie a surgical splint to in the event that the sur-
geon wants to leave a surgical splint in place post
operatively. This becomes especially critical
when multiple piece maxillary surgery is being
performed.
As the case is ordered a pictorial description
populates to visually indicate the order. Several
choices are offered for indirect bonding trays. A
standard silicone tray is offered where the brack-
ets are buried in silicone and the backs of the
brackets are pretreated for indirect bonding.
There is also a clear 2 piece tray system which
allows for light cured glue to be used to bond the
brackets. Last and potentially most important,
you have the choice of a clear precision tray to
bond the brackets in place. This tray in my esti-
mation is the best choice as it is built directly
301
from digital data and guarantees that the bond
position of the teeth is correct. It is important to
know that the backs of the brackets in this choice
are smooth and untreated. So you must remem-
ber to use an adhesive that has a metal primer
built into it such as Rely X Yellow from 3 M ESPE
or you will need to place a metal primer on the
backs of the brackets yourself.
If you have a tooth such as a canine where it is
blocked out of the arch, and the lingual surface is
clearly visible, you have the option to include it in
the indirect bonding tray or to have it built and
separately delivered for individualized bonding.
My preference after doing it both ways for many
years is to have the bracket provided separately
only after the space is established. When all of the
brackets are being placed into the bonding tray
the tooth that is blocked out is most likely to have
the bracket placed off center on the bonding pad.
All of the teeth will be bonded but the blocked out
tooth will offset the bracket position. This can
occasionally lead to finishing and rotational issues
at the end of the case. Therefore I prefer to make
my space with advanced copper nickel titanium
arch wires and compressed niti open coil. Once
302 Warshawsky
the space is fully created, I will bond my bracket to
incorporate the tooth into the arch. Waiting to
bond the bracket body will result in the bracket
being centered on the bonding pad, which ulti-
mately equates to simpler placement of the final
arch wires and the most efficient alignment of the
teeth.
Finally, when ordering a surgical case you
must decide if you need 2 sets of wires, that is
presurgical and postsurgical wires. 2 sets of wires
is the obvious choice when either the maxilla is
being cut into multiple pieces or a tooth is being
removed. I would recommend working up to a
016 £ 024 stainless steel wire presurgically. A
multi-piece maxilla will need to determine which
teeth if any are to be removed. Surgical segments
are reproximated together in the operating
room today typically by using a preprinted splint.
If it is the transverse dimension of the teeth that
is being addressed at a surgical level, you can
choose to expand or narrow the steel wire pre-
surgically.
Our first case to discuss is a unilateral crossbite
where the patient has outgrown her orthodontic
correction. Using a scanner and TMP platform
you may plan for a correction using the Incog-
nito Custom Lingual bracket system. The screen-
shot of the digital Setup (see Fig. 2) indicated
that the maxillary arch form was considerably
wider at the end of the case compared to original
malocclusion. Therefore, once the patient is able
to handle postoperative orthodontic care, you
will need to place your new corrected arch wire
with the proper canine eminence position (this
is referred to as the postoperative wire).
It will be your choice if you want the surgeon
to cut the arch wire at the time of surgery, or you
can do it yourself in advance of surgery. How-
ever, if the surgeon decides to cut the wire make
sure that your surgeon sections the wire distal to
where the maxillary jaw is being sectioned. Post
operatively you want to place a continuous
016 £ 022 or an 018 £ 025 copper or SE niti wire
to allow the teeth to RE-level and align given the
new expanded archform. When in doubt, and
due to the fact that custom wires take a few weeks
to order and receive, I strongly suggest that you
go ahead and make sure that you have an extra
wire or two as your case goes to surgery.
Depending on your surgeon’s skillset and
comfort with digital records, you will need to
determine several things prior to surgery.
Although rigid fixation is the preferred method
of stabilization of the jaws, at the completion of
surgery, some surgeons still prefer to leave a sur-
gical splint inter-occlusally with intermaxillary
elastics and IV loops for support. This may
remain for 4 8 weeks to further ensure that
occlusal stabilization is not disturbed thus pro-
moting uneventful healing of the patient prior to
the resumption of orthodontics care. Using the
Incognito saddle bands on the posterior molars
has the added benefit of built in labial traction
points for occlusal stabilization. The bands are
built in a manner to not intentionally open the
posterior bite. Therefore overall the occlusion
fits very well.
In our practice we use an all digital work flow.
When a patient is deamed surgically decompen-
sated and ready to book with the surgeon, we
take a chairside oral scan, a fresh conebeam, and
new photographs. The Incognito system is
completely customized and built using a digital
workflow. As such it favors digital diagnostic
records to design and build the appliance. It is
very important to understand that 3 M believes
that all custom work flows should be open plat-
forms. Doctors should not be excluded from
using any of the current or future 3 M custom
products based on the brand of the scanner that
was used to aquire the digital scan.
The most popular intraoral scanners includ-
ing but not limited to Itero, 3shape, and of
course the 3 m True Definition scanner are
often utilized to achieve such work. All scanners
have their merits and drawbacks. Whether it is
the size of the scanning computer hardware,
using powder, local vs. cloud based storage, or
the size of the scanner wand itself, many factors
will need to be considered when purchasing a
tool of such significance. Personally, I use the
3 M True Definition Mobile scanner. Given that
the scanner wand is the smallest in the industry
and the computer to run it is a modified Micro-
soft surface weighing in less than 5 lbs, we can
move it with ease and not disrupt the office
flow significantly to capture our digital impres-
sions.
 Appreciating the art of custom surgical orthodontic care
Figure 2. Tru def portable.
Using a digital workflow has many unique
advantages. One of these is the ability to print
progress models. Using the 3 M Oral Care Plat-
form, I like to order printed models on a small
plastic articulator. Presurgically I will rescan my
case between 6 and 8 months to order a set of
progress models. You can request to have your
orthodontic appliances digitally erased. This is a
very unique option where you may see exactly
how much correction you have accomplished.
The base of these models have a unique honey-
comb lock that fits in the articulator base. By
removing the models from the plastic articulator
this allows you to hand articulate the models to
assess your occlusal stability while still retaining
the option to remount your case. I believe the
time savings here is incredibly significant. The
quality of the models is predictable, and your
assessment for the viability for surgery is signifi-
cantly easier than attempting to capture alginate
impressions, especially understanding that the
appliances are on the lingual. If a case is deamed
surgically ready, then I believe duplicating the
printed models for a surgical splint is a simple
process and it may be assessed and confirmed on
the actual teeth prior to going to surgery.
Lastly, I will ask the surgeon what he/she is
most comfortable with for the outside of the
teeth that have the Incognito appliance. Choices
are Bondable Buttons, Tad’s, or a passive labial
appliance to make the surgeon’s job as predict-
able as possible. Many times I place a full labial
appliance from second premolar to second pre-
molar with a passive 017 £ 025 passive stainless
steel wire with welded surgical hooks for intra-
arch ligation in the operating room for the
303
surgeon. I never want to jeopardize a patient just
for cosmetics. As a result of the labial braces, I
will actually remove the lingual wire for surgery.
Again, the posterior saddle bands have lugs cast
on the buccal for traction as a part of the original
Lingual custom order. What all three of the tech-
niques I have described here have in common is
that the lingual braces were not removed for sur-
gery.
Both the vertical as well as the horizontal
dimension is well controlled when discussing the
Incognito Appliance System. We will start by dis-
cussing Maxillary Surgical Procedures. Being a
custom appliance, Incognito has a unique advan-
tage in that you may build your appliance to actu-
ally complement the mechanics. In cases where
the Posterior vertical dimension is excessive, I
starting with gold half pad onlays as part of the
design build which takes the anterior teeth out
of occlusion. In general, teeth will move faster
when they are not in occlusion. Your coverage
may be in the form of a half occlusal pad, a full
occlusal pad, or what we refer to as a “Saddle
band” where the gold only sits on the marginal
ridges. The teeth may be leveled and aligned so
that the occlusal plane is flat including the gold
onlay cusp tips. What this actually does over time
is intrudes the posterior teeth slightly. Adding
half pads also increases retention so once you
figure out how to design the Incognito system to
augment your cause I think you will see few bro-
ken brackets, at least form occlusion. Upon ini-
tial bonding the anterior openbite will be worse
for sure with occlusal gold coverage. Vertical elas-
tics will extrude the anterior teeth and in what I
refer to as the “Teeter totter effect”. It will help
304 Warshawsky
to vertically intrude the opposite end of the den-
tal arch (posterior) which will mildly intrude pre-
surgically. The net effect is to level and align the
posterior teeth with the anterior teeth. Towards
the end of the case post operatively you just need
to remember to remove the occlusal gold or you
will have a slight posterior openbite upon
debanding.
Straight forward single jaw surgical cases have
now been adapted to a digital workflow. We print
and mount our3D print the models (Fig. 3A) to
assess the surgical move at hand. A chairside
intraoral scan (COS) is much simpler to obtain
than alginates to assess our progress. Typically,
we print a horseshoe style model, but if the sur-
gery is a proposed multipiece maxilla, we will
print a full palate on the upper dental model.
Confirming the occlusion is simple. Once
done my surgeon and I can perform simple
model surgery to dictate the size and direction of
the needed move. We will remount the case
(Fig. 3B) to make sure that in fact the movement
makes sense and is achievable.
Once the mounting has been verified by both
the surgeon and myself, if the move seems rela-
tively straight forward we fabricate a simple surgi-
cal acrylic splint. This appliance can be sterilized
and go into the operating room the day of the
Figure 3A. Printed Models Mounted for surgical splint building.
Figure 3B. Models Remounted for surgery.
surgery. For this specific case, a space is required
between the lateral and canine to create the
osteotomy to enact a unilateral asymmetrical
skeletal correction of a crossbite. Postoperatively
this space will be maintained and closed with
restorative dentistry so that our Bolton Ratio is
acceptable and functional stability in the occlu-
sion is achieved (Fig. 3C).
Within 14 days of surgery our protocol will
recall our patient for Facial Photographs, 1 intrao-
ral photograph and a progress conebeam xray to
confirm the occlusion is proper and that the con-
dyles are seated properly in the fossa. Six to eight
weeks post-op we will take control back from the
surgeon and we will resume orthodontics to wrap
up the orthodontic case. In general I hope to be
completely done with orthodontics 3 6 months
following the completion of surgery.
In this image you can visualize that the model
surgery matches the physical position achieved
in Operating Room once the case is plated into
position (Fig. 3D).
The image to the left shows the surgical splint
after it has been left in place for 18 days. Position
is identical to what was planned. Due to the unor-
thodox osteotomy on this case the splint was left
in for almost 4 weeks prior to removing it to allow
the start of skeletal healing (Fig. 3E).
 Appreciating the art of custom surgical orthodontic care 305

Figure 3C. Simple Surgical Splint built from 3D Printed models.

Figure 3D. Visualization of Surgical correction to the presurgical setup.

Figure 3E. 3 Week Post Op Splint check prior to splint removal.

Case 2 obvious. The plan for a case such as this is to do a

Leforte I osteotomy and remove a wedge of poste-
The Second case to discuss is an anterior open bite
rior bone to help assist to change the occlusal plane
where maxillary posterior hyperplasia is significantly
and close the anterior openbite. The Incognito
306 Warshawsky

Figure 4A. Failed Invisalign Case with Skeletal openbite.

Appliance system is very effective in preparing a position. Given that the system has a vertical ribbon
case for surgery because it prebuilds all archwires in arch orientation there is almost 36% more wire sur-
advance to level and align the teeth to an ideal face to deliver torque to the teeth. This extra wire

Figure 4B. Ceph Analysis of Openbite case.

 Appreciating the art of custom surgical orthodontic care 307

Figure 4C. Presurgical Progress on openbite.

when applied properly is incredible effective at
establishing the new anterior torque of the incisors
and canines (Fig. 4A).
The next case we will review here has had
Invisalign therapy for approximately 4 years.
There is a significant anterior openbite, and
tooth #9 is a dental implant that is placed argu-
ably in a tough position to achieve a successful
cosmetic result (Fig. 4B).
The implant at tooth #9 represents a difficult
twist on this case as cosmetically it is not placed
in an ideal manner. Since the implant cannot
move we will design the maxillary orthognathic
move around the final restorative crown on the
implant. The restorative dentist, the patient, and
myself sat before the case initiated and we
decided that when the case wrapped up we
would add a mm or so to the length of #9. After

Figure 4D. Progress Cephalometric Film.

308 Warshawsky

Figure 4E. Post Operative Cephalometric film.

Figure 4F. Post Operative Occlusion.

consultation with the patient she understood
that the tooth will look shorter than the sur-
rounding teeth throughout her presurgical
orthodontic phase.(see Fig. 4C)
Errors in the occlusion tend to be easy to spot
(In this example the upper left central is an
implant provisional crown, the left lateral incisor
and canine are significantly askew) and the
occlusion may be modified based on the feed-
back that is learned from the modeling. This spe-
cific case had to operate within a certain time
period or insurance coverage would be lost.
Therefore, this case went to surgery not fully lev-
eled and aligned. I was not worried though as I
know the teeth would complete aligning once
the full size niti ribbon arches had an opportu-
nity to work. Depending on the surgeon that I
am working with that will determine what I will
be placing on the teeth to assist the fixation in
the operating room. Again, once the teeth are in
an acceptable position, it is conceivable to fabri-
cate a surgical splint off of the printed progress
models to help the surgeon guarantee the final
position of the teeth.
Progress Cephalometric film (Fig. 4D)on the
current case indicates the leveling of the teeth.
Note the dental implant in the position of tooth
#9. This case is designed around the position of
this tooth to maximize restorative cosmetic solu-
tions and the occlusion,.
 Appreciating the art of custom surgical orthodontic care
Figure 4G. Obtained Final Occlusion.
The preoperative cephalometric film shows
the anterior openbite quite clearly. Once surgery
is performed we repeat the diagnostic records
within 2 weeks to the level that the patient will
tolerate to confirm the correction of the maloc-
clusion is accurate and matches our modeling.
The post operative Cephalometric film
(Fig. 4E) for this patient following a Leforte I
osteotomy with a differential impaction indicates
the occlusion is completely integrated and the
anterior openbite has been resolved (Fig. 4F).
Note buccal appliances were passively placed
with 019 £ 025 ss arch wires and surgical hooks for
surgery. The case was debanded approximately
6 months following the completion of surgery. The
final restorative work to re-restore the implant will
occur some months after the case is completed.
Retention will be a fixed lower wire with a clear
maxillary aligner to protect the upper teeth. The
upper aligner will be changed out as the implant
crown will be replaced over time (Fig. 4G).
Case 3
The next topic to discuss is when transverse defi-
ciency is an issue and a LeForte I procedure is
NOT an option. There are many reasons
why you may not consider a doing a 2 Piece
Leforte Osteotomy to resolve severe transverse
issues. An alternative treatment plan may utilize
a Surgically
Assisted Rapid Palatal Expander(SARPE) to
resolve the transverse issue. The patient we will
discuss saw me 3 years previous to starting with
309
me an opted to not treat out at first. He had
already had comprehensive orthodontics as a
late teenager and experienced significant decal-
cifications. He was disappointed in the result but
not convinced that he had to reattempt treat-
ment. After chipping several teeth over the next
few years he decided that he needed to correct
his bite or he thought he would ruin his teeth.
(See Fig. 5A). However, my patient was getting
married so he requested lingual braces and no
Leforte I Osteotomy for esthetic reasoning. I was
OK with his decision to request lingual braces. I
have yet to see decalcifications due to Incognito
so I was sure his teeth would not experience fur-
ther decalcifications. I utilized the Incognito sys-
tem for his care because I felt it had several
advantages. The posterior wire is a 025 £ 018
edge wise slot which gives the wire over 24%
more surface than a 019 £ 025 wire in 022 £ 028
wire slot. Unlike labial appliances it is not
unusual to order a full size wire to completely fill
the slot. Circumstances to think about in Rapid
expansion with Incognito involve how to mount
the expander, when to take the scan to build the
incognito, how to place the braces, (i.e. Directly
or Indirectly), Will you place a pontic, what size
wire will you close space on, and should you
order distal offset bends on your canines to com-
pensate for the expansion of the teeth.
The case presented here had already been
through orthodontics, so when he decided to ini-
tiate orthodontics he was immediately ready to
proceed and we took records. We were about 16
months out from his wedding date and I was
310 Warshawsky

Figure 5A. Images of Bilateral posterior crossbite.

worried that I may not be done for his wedding. I
voiced my concerns regarding the timing of the
case so to maximize the time prior to the wed-
ding I chose not to use a custom indirect bond-
ing tray. Therefore when building a SARPE with
Incognito write in the prescription in TMP(3 M
Treatment Management Portal) the desire for
Direct Placement of your braces. The anterior 6
brackets will come individually wrapped and
labeled with incisal gold fingers to hold
the bracket steady as it is being light cured. As
wire design goes, you need to estimate the size of
the diastema that may generate with a case like
this. If you take the width of the proposed dia-
stema and divide it by two it will give you an idea
of the distance you need to request your canine
offsets be moved to the distal on your first 2 niti
wires. Since you will be closing space and
Incognito is a ribbon Arch, you must be careful
that the teeth do not severely tip. As a result, I
recommend that your first wire be larger than
normal such as 016 or 016 £ 016 se niti, and that
your second wire should be 016 £ 022 se niti. I
extend the canine offset bend on only the first
two wires as I assume that the majority of the
space created from the expander will be man-
aged by the time I place my third arch wire. If I
were offering advice I would also consider order-
ing 2 of the first arch wire. In this scenario I rec-
ommend starting your partial bonding of the
upper arch 6 weeks out post surgery. The brackets
may be placed from canine to canine leaving your
expander in place. I cut the first wire distal to the
canine. I remove the palate expander 8 10 weeks
after surgery, place my remaining braces and uti-
lize a full size arch wire for excess space consolida-

Figure 5B. Images of Sarpe Fully expanded.

 Appreciating the art of custom surgical orthodontic care 311

Figure 5C. Images of Space closure.

Figure 5D. Completed case SARPEjumped xbite.

tion. I have become more aggressive and have
learned to initiate orthodontic care much quicker
to manage my tooth position. Getting in prior to
the bone being fully healed allows for more effi-
cient space management. The last three wires can
all be built at ideal length. I also recommend that
you place bands on the first molars with an auxil-
lary sheath for a TP bar so that if you feel the
need for further support post removal of your
expander you may add an auxillary such as trans-
palatal bar to your case (Fig. 5B).
Once active expansion is complete I bond a
pontic in the diastema to reduce any ill feelings
that the patient may be experiencing due to
esthetical compromise the diastema created.
Once bonding starts I tend to reduce the pontic
visit to visit. The actual rapid expander can be
removed 10 12 weeks after the expansion was
completed. Posterior appliances may be
immediately bonded once the expander appli-
ance has been removed. Due to their positive fit
and unique anatomy I do not feel that there will
be many issues directly bonding these applian-
ces. If the space between the teeth is large we
tend to bond a pontic to hide the space that is
generated from the orthopedic expansion. As
the space closes we trim the pontic (See Fig. 5C).
In general, I expect to resolve my severe
transverse discrepancy cases in under 16
months once I complete the orthopedic expan-
sion. The images below indicate the occlusion
that we were able to achieve once the upper jaw
was properly expanded. Given the patient had
already been through orthodontics twice prior
to meeting me, and he would not allow me to
consider orthognathic surgical options, I was
pleased with the result that I achieved see
Fig. 5D.
312 Warshawsky
Switching our focus to mandibular issues I
would like to discuss mandibular prognathism
where the mandible is being set back. As with
most prognathic cases, your goal will be to
decompensate the case which will make it look
worse before surgery. Decompensation can vary
depending on your needs. If the midface is flat
and pogonion is well positioned, you will be
required to add torque to the upper teeth to up
right them and center them in the alveolar cor-
tex of the anterior maxilla. If these teeth are
excessively flared then it is likely you will con-
sider removing the upper first premolars to
retract the incisors creating adequate negative
overjet to prepare for surgery. The goal is to
work your wires to establish anterior torque in
the front teeth and in the process, create an
underbite to allow for forward movement of the
maxilla. Little problems are hard to fix surgically.
Therefore, pre-surgically we tend to make them
more noticeable while we constantly monitoring
the airway to make sure we do not make it worse.
Once the steel wires have been placed for at least
6 weeks, all IPR has been performed, and the
spaces have all been consolidated, it is worth tak-
ing a progress scan and printing the models to
check arch coordination. The strength in the
Incognito custom setup, is that you may view this
relationship virtually in the model notes prior to
approving casting the bracket bodies and build-
ing your custom arch wires. Most of the time I
find the occlusion meets predictably, and that
vertical elastics in conjunction with the rigid
Figure 6A. Adolescent Class III malocclusion.
fixation is enough to stabilize the patient post
operatively.
Case 4
This case is an example of a teenager (See
Fig. 6A) that I monitored for quite some time.
She had Class III tendency, and mom had double
jaw surgery in college. I suspect that this patient
may require surgery so I continued to monitor
her growth and took serial cephalometric images.
She went through puberty around 12 years old. I
watched her for almost 5 years before we enter-
tained the concept of treating her (Fig. 6C). (See
Start cephalometric film Fig. 6B) Once I had 2
consecutive cephalometric images where I felt
there was no change I opted to initiate care. This
was an elective procedure, so I planned to have
the surgery done at a time when it would not
interfere with school (Fig. 6D).
She was significantly Class III by the time treat-
ment started and I needed a 6 month window to
decompensate the teeth as well as remove the
wisdom teeth to allow the extraction sites to heal
as the mandibular setback would cut right
through this zone. It should be noted that she
also presented with a Bolton discrepancy in the
upper dental arch. She had maxillary peg lateral
incisors. The treatment plan included in addi-
tion to a mandibular setback, to open space
around the upper lateral incisors to achieve a
normal Bolton Ratio between the upper and the
lower teeth. As a senior in high school at the
 Appreciating the art of custom surgical orthodontic care 313

Figure 6B. Cephalometric analysis of Class III malocclusion.

Figure 6C. Start of Orthodontics Class III Malocclusion.

Figure 6D. Panorex at start indicating wisdom teeth needed to be removed.

314 Warshawsky

Figure 6E. Progressive Surgical Decompensation.

Figure 6F. 2Week Post Operative Check.

time of treatment she was not happy to be start-
ing orthodontics. To pacify her esthetic concerns
she chose to use Incognito due to its superior
esthetics as well as I believe its mechanical effi-
ciency. See Fig. 6E to show decompensation
progress prior to going to surgery.
My surgeon requested a full set of labial
braces so the presurgical images indicate braces
on both sides of the teeth with the lingual wires
out.
15 days following the surgical correction of her
prognathism we took records to document the
move and her healing. See Fig. 6F
Post-surgical mechanics involved detailing of
the arch wires as well elastics to help achieve a
final class I occlusion.
A harmonius profile was achieved with a Class
I occlusion. Following orthodontics teeth 7 and
10 were bonded to fulfill the objectives of surgery
(Figs. 6G and 6H).
 Appreciating the art of custom surgical orthodontic care 315

Figure 6G. Final occlusion compared to the initial maocclusion.

Figure 6H. Final Profile Change as a result of surgery.

Case 5 ordering models from the Unitek Treatment

management portal you can request brackets to
Next case to consider is a patient who has a defi-
be erased, models to be placed in a plastic articu-
cient mandible. Today airway has become a rec-
lator, maxillary palate may be added, or a horse-
ognized hot topic in orthodontics. We now know
shoe model may be printed instead.
that many deep bite class II cases reap the bene-
The case shown below is a significant class II
fits of a mandibular advancement. In general, it
Div2 (Fig. 7A).
is difficult to level a severe curve of Spee. Incog-
In this malocclusion the curve of Spee was far
nito has 2 definitive advantages when working in
from level. So the advantage of utilizing Incog-
the vertical dimension. The first is that it is a rib-
nito is the ability to custom build the appliance
bon arch and as such has more power to level
to efficiently level the overbite and the occlusal
the teeth given that is has almost a third more
plane (Figs. 7B and 7C).
wire surface than an 018 £ 025 edgewise wire.
The cephalometric xrays indicate the signifi-
The second trick with Incognito that is very effec-
cant leveling that occurs (Fig. 7D) within a short
tive is that you may order custom 1/2 occlusal
period of time (less than 6 months) when Incog-
pads on your posterior teeth that are true repre-
nito is propery utilized. Within 6 months the
sentations of the anatomy of the teeth. This is
overbite is managed in a controlled manner
very useful when bites are deep and you need to
(Figs. 7E and 7F).
disclude the teeth to start to move them. Once
Don’t be fooled though by the photographs.
the teeth are perceived to be leveled and aligned
This patient automatically positions his jaw for-
then it is reasonable to scan the teeth and print a
ward in photos. If you look closely you will notice
set of models to test the occlusion. When
the cephalometric x ray indicated a significant
316 Warshawsky

Figure 7A. Class II Divisioin 2 Maloclusion Initial Records.

Figure 7B. Ceph analysis of class II div2.

increase in overjet. A decision was made to take
progress models to check the occlusal integrity
of the teeth. For the best patient experience and
the greatest accuracy a chair side oral scan of the
teeth it obtained. The scan produces STL images
which can be easily managed and printed to
assess the occlusal integrity. It is about this time
we will print the models and evaluate final posi-
tioning for surgery. For this specific case we
debated regarding whether or not surgery
should address 1 jaw or 2. Ultimately when all of
the facts were gathered we decided to surgically
advance only the mandible. We opted to leave
the maxilla alone as the patient lived in North
Carolina and I am in Chicago. Based on our
goals and objectives to improve his occlusion not
only would 1 jaw of surgery answer his desires, it
would provide a much less complicated healing
process. So once it is deemed that he is accept-
able for surgery we take full records, plan our
case using virtual surgical planning (VSP) from
Medical Modeling and utilize the printed model
 Appreciating the art of custom surgical orthodontic care 317

Figure 7C. Traced Cephalometric film of the original malocclusion.

Figure 7D. Dental decompensation that resulted from leveling the teeth dentally.

Figure 7E. Progress records indicating surgical decompensation.

318 Warshawsky

Figure 7F. Initial Malocclusion Buccal and Anteriro view.

Figure 7G. 4 Month progress record of Buccal and Anterior Occlusion.

to confirm that the surgical splint that we printed
or hand built is in fact accurate. The proof is in
the records of how we performed. This is a total
of a 7 mm mandibular advancement and overall
it went well (Figs. 7G and 7H).
12 Months of surgical Decompensation
deemed ready for surgery. Note Digital Models
had the braces digitally erased to be able to view
the position of the teeth better. This service is
available from 3 M Oral Healthcare.
Final scans of teeth (Fig. 7I) showing a passive
labial appliance with steel wires per the request
of the surgeon. Due to the size of the mandibular
advancement we wired the surgical interposi-
tional splint in place for 3 weeks to allow the sur-
gical sites and opportunity to mature prior to

Figure 7H. 12 Progress records to Assess feasability for surgery.

 Appreciating the art of custom surgical orthodontic care 319

Figure 7I. Final printed models presurgically poitioned with interpositional wafer for surgery.

Figure 7J. Final traced cephalometric xray.

placing elastics and finishing wires. Note the
clear splint is interposed between the upper and
lower models. It is typically wired to the upper
teeth in the operating room.
Intraoperative cutting guides as well as the final
splint are printed with the virtual surgical planning
software that is used to plan the case. The VSP soft-
ware will indicate proper dental occlusion in addi-
tion to providing inter-positional cutting guides
exactly where the osteotomies are to be performed,
where inter-positional bone grafts need to remain,
and of course where the ideal placement of the
Rigid Fixation would be most ideal. Technology
allows all individuals associated with the case to
attend the surgical planning session on line.
Typically our session is complete in under 20 min,
and the outcome will yield surgical maps with real
time values to indicate the quantitative values

Figure 7K. Before and after Cephalometric xrays.

320 Warshawsky

Figure 8A. Buccal and Anterior view of a full cross bite with occlusal cant.

indicative of tooth movement. The software will Case 6

then print surgical cutting guides, custom plastic
The last case to discuss is a Skeletal Dysmorphia
fixation plates, as well as post-operative inter-
where there the only proper solution is to plan com-
maxillary occlusal splints as well as a paper
prehensive orthodontics combined with orthog-
representation of the entire move well in
nathic double jaw surgery to level both the upper as
advance of the surgical date. There are many
well as the lower teeth. To complicate matters the
advantages to this technique the least of which
patient did not live in Illinois and traveled to see
is the surgeons ability to familiarize themselves
me. Therefore trust in the appliance to level the
with the anatomy of the actual patient. We find
teeth and set them up for surgery was critical. I
in general if given the option to use this tech-
wanted to be sure what ever appliances I used was
nique, it is almost exclusively favored as the
most likely to get the job done. Incognito appliances
actual time in the Operating room is less and
are strongly recommended in our practice for a
the fit of the teeth tends to be more predictable.
problem such as this due to their advantage of being
Approximately 7 months post surgery the case
custom made. Not only do they look superior to
was completed. The patient flew back to Chicago
other orthodontic solutions, it is very easy to judge
to remove the orthodontic hardware (Figs. 7J
the progress of the case. Superior visibility, efficient
and 7K).
custom made appliances and wires, and premium
The traced cephalometric film shows that a
esthetics are just a few of the reasons why I use
solid Class I skeletal relationship was achieved.
Incognito appliances to set cases up for surgery
The lower facial height increased almost 7 mm as
(Figs. 8A and 8B).
a result of orthognathic surgery.

Figure 8B. Presurgical Prediction of the existing malocclusion.

 Appreciating the art of custom surgical orthodontic care
Figure 8C. Progress Records showing surgical decompensation.
When planning for jaw surgery I will plan to
decompensate both the upper as well as the lower
teeth to ideal position. Once done the appearance
of the teeth to one another will be poor, but the
position of the teeth relative to the bone will be ide-
alized. So patients are warned that their malocclu-
sion will likely worsen prior to surgery. Utilizing the
images from the treatment management portal, you
should be able to directly compare the patient to
the planned predictions in the software and they
should be similar.
When taking progress records of the case you
should be able to make a direct visual compari-
son from the planned stage to the actual stage.
This ability for a visual confirmation is a distinct
advantage in lingual braces.
Once we have determined that the alignment
of the teeth is approximately what we had
predicted to occur, we take full diagnostic
records (Fig. 8C) in preparation for Orthog-
nathic planning. We utilize Virtual Surgical Plan-
ning from Medical Modeling in Colorado to
help predict the outcome for the surgery.
Between the conebeam xray, full 2D and 3D pho-
tography, and lastly a chairside oral scan, we pro-
vide Medical Modeling with the entire case in
3D. Surgical moves are planned in all 3 planes of
space and through the software a complete surgi-
cal plan is created (Fig. 8D)
The system provides individual occlusal wafers
to assist the surgeon through the various surgical
321
stages where both the upper and lower jaws are
being moved. The wafers indicate where the sur-
geon should cut at each individual stage of sur-
gery. You will note that in these photos the
patient is 6 weeks post operative. Upper labial
braces were added just for surgery to assist the
surgeon to ligate the jaws
Fig. 8E You will note that the 6 week post
images show the midline is not centered.
Note in Fig. 8F the post op image matched the
pre-surgical prediction very closely.
Approximately 90 days after surgery the case
was completed and the appliances were. See
Fig. 8G The occlusion was stable and the dental
midlines were lined up.
In general, this article reviewed the concept
of using Incognito lingual appliances with
various types of surgical augmentation to assist
the orthodontist when surgically correcting
a patient skeletal dysplasia. Custom made
brackets and wires, 3 dimensional diagnostic
records, and careful planning are just a few of
the reasons why Incognito is so effective at
treating complex malocclusions. A preprog-
rammed custom orthodontic appliance system
like Incognito helps to deliver efficiently pre-
dictable presurgically coordinated dental
arches. Its ultimate strength is the ability to
minimizing the hardware appearance in the
months of preparation leading up to the
surgical correction of the malocclusion.
322 Warshawsky

Figure 8D. Virtual Surgical planningTM Software.

 Appreciating the art of custom surgical orthodontic care 323

Figure 8E. 6 Week post op records.

Figure 8F. Post Op records compared to predicted finish.

Figure 8G. Final Results double jaw surgery.

324 Warshawsky

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1. Grauer D, Proffit WR. Accuracy in tooth positioning
with a fully customized lingual orthodontic appliance. Am
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2. Van der Veen MH, Attin R, Schwestka-Polly R, Wiechmann
D. Caries outcomes after orthodontic treatment with fixed
Oral Sci. 2010;118June(3):298–303.
3. Kairalla SA, Galiano A, Paranhos LR. Lingual orthodontics
as an aesthetic resource in the preparation of orthodon-
tic/surgical treatment. Int J Orthodontics Milwaukee. 2014;25
(2):31–35. Summer.