The “holy grail” of patients, particularly adults, in need of orthodontic therapy to align teeth or correct bites would be with an “invisible” technique capable of achieving the accuracy, predictability and cost effectiveness of conventional braces on the front of the teeth. Tooth colored ceramic braces provide a much improved though still visible appearance with results equal in quality to conventional metallic braces. Clear aligners (Invisalign for example) represent a much advertised and popular removable appliance technique which studies show are considerably less accurate and predictable than conventional braces and where the relative value received for the price is in my view less than desirable. There have been multiple attempts over the years at creating a lingual system that is consistent in quality and predictability as compared to the front braces. Their development required overcoming multiple obstacles including high variability of lingual tooth anatomy as compared to the front, smaller distances between brackets on the lingual, the inability of doctors to accurately create complex archwires with multiple three dimensional bends chairside and adhesive technology capable of keeping the lingual braces attached in the demanding oral environment. Our past experiences with lingual systems were unsatisfactory to the point where we referred out those insistent on using it because we were not pleased with the outcomes.
The introduction of the Incognito appliance by the Unitek division of 3M, on which we have become a certified provider, represents a dramatic leap forward in orthodontic technology made possible with the use of robotics to create precise and consistent archwires capable of achieving three dimensional control of each tooth position as well as customized lingual braces specific for each tooth on each patient. By contrast, conventional braces are ordered with standard prescriptions and adjusted with archwires created chairside by the doctor. As one might expect, this customization of braces and archwires is quite costly as compared to conventional braces and therefore is unlikely to become the standard of care going forward except for those patients who demand maximum aesthetics and high quality results with a lesser concern for the value received with respect to cost. Lingual treatments also may take longer to complete in certain case types and present more of an initial but temporary speech impediment. Adhesive technology has now advanced to the point where we can reliably attach (bond) braces to natural teeth, porcelain crowns and veneers and even to metallic crowns when needed.
There are several such engineered systems also marketed for front braces with some making claims of faster treatment times and/or better results than conventional braces. At this time, however, I am unaware of any randomized controlled study which would support those claims other than anecdotal ones. At least for now, patients willing to tolerate the front braces are in my opinion best served with conventional braces (metal or ceramic) capable of being adjusted chairside without the need for robotic archwire creation as we routinely manually accomplish now with excellent results. It is important to restate that there is more than one way to accomplish accurate tooth movements but if the result is not stabilized with bonded retainers placed behind and individually attached to both the upper and lower front teeth, relapse is likely to occur once the braces are removed irrespective of which method was used to treat the case.
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