Earn 3 CE credits This course was written for dentists, dental hygienists, and assistants.

Orthodontic Treatment with A Peer-Reviewed Publication Written by Ken Fischer, DDS

Abstract Educational Objectives Author Profile Since its inception, the methodology of using clear Upon completion of this course, the reader ClearCorrect™ Clinical Advisor, Ken Fischer , DDS received his aligners [Figure 1] or trays as a means of sequentially should be able to: orthodontic certificate from UCLA in 1975 and has maintained straightening teeth has evolved significantly to where, 1. Be familiar with the components of the his private practice of in Villa Park, California. today, the technique has been adopted by many clear aligner system; Dr. Fischer was an early adopter of clear aligner treatment dentists wanting to provide some degree of orthodontic 2. Understand that clear aligners are in 2000 and has treated nearly 1,500 patients with clear correction for their patients. Once limited to correcting capable of treating a broad spectrum of aligners. He has shared his treatment experiences with both small amounts of crowding or spaces in fully erupted ; and domestic and international audiences, published a number dentitions, it is now utilized by experienced clinicians 3. Appreciate the complexities of of articles regarding clear aligners, and has also served as a in a broad spectrum of the comprehensive treatment mastering orthodontic treatment with clinical advisor for Invisalign™. of complex . This course will trace that clear aligners. evolution and document the validity of using clear Author Disclosure aligners in contemporary orthodontic treatment. Ken Fischer, DDS, is a clinical advisor for the sponsor of the unrestricted educational grant for this course.

INSTANT EXAM CODE 15167 Go Green, Go Online to take your course

Publication date: July 2017 Supplement to PennWell Publications Expiration date: June 2020

This educational activity was made possible through an unrestricted educational grant by ClearCorrect™. This course was written for dentists, dental hygienists and assistants, from novice to skilled. Educational Methods: This course is a self-instructional journal and web activity. Provider Disclosure: PennWell does not have a leadership position or a commercial interest in any products or services discussed or shared in this educational activity nor with the commercial supporter. No manufacturer or third party has had any input into the development of course content. Requirements for Successful Completion: To obtain 3 CE credits for this educational activity you must pay the required fee, review the material, complete the course evaluation and obtain a score of at least 70%. CE Planner Disclosure: Heather Hodges, CE Coordinator does not have a leadership or commercial interest with products PennWell designates this activity for 3 continuing educational credits. or services discussed in this educational activity. Heather can be reached at [email protected] Educational Disclaimer: Completing a single continuing education course does not provide enough information to result Dental Board of California: Provider 4527, course registration number CA# 03-4527-15167 in the participant being an expert in the field related to the course topic. It is a combination of many educational courses “This course meets the Dental Board of California’s requirements for 3 units of continuing education.” and clinical experience that allows the participant to develop skills and expertise. Image Authenticity Statement: The images in this educational activity have not been altered. ©PENNWELL®2017The PennWell Corporation is designated as an Approved PACE Program Provider by the Scientific Integrity Statement: Information shared in this CE course is developed from clinical research and represents Academy of General Dentistry. The formal continuing dental education programs of this the most current information available from evidence based dentistry. program provider are accepted by the AGD for Fellowship, Mastership and membership Known Benefits and Limitations of the Data: The information presented in this educational activity is derived from the data and information contained in reference section. The research data is extensive and provides direct benefit to the patient maintenance credit. Approval does not imply acceptance by a state or provincial board of and improvements in oral health. dentistry or AGD endorsement. The current term of approval extends from (11/1/2015) to Registration: The cost of this CE course is $59.00 for 3 CE credits. (10/31/2019) Provider ID# 320452. Cancellation/Refund Policy: Any participant who is not 100% satisfied with this course can request a full refund by contacting PennWell in writing. Educational Objectives resetting teeth by developing a process for vacuum forming a Upon completion of this course, the reader should be able to: piece of clear plastic to tightly encase the teeth on a stone mod- 1. Be familiar with the components of the clear aligner el.2 [Figure 4] Dr. Nahoum used his mother’s WILFA vacuum system; cleaner to create a vacuum in a 55-gallon drum. He connected 2. Understand that clear aligners are capable of treating a a butterfly gate valve to the top of the drum and set an inverted broad spectrum of malocclusion; and coffee can onto the gate valve. Next, he placed a stone model 3. Appreciate the complexities of mastering orthodontic of the teeth covered by a thin piece of plastic on the perforated treatment with clear aligners. bottom. After heating the plastic with his mother’s flat iron to just the right temperature, he opened the gate valve and the Abstract/Introduction vacuum created in the drum pulled the plastic down over the Since its inception, the methodology of using clear aligners stone model, forming a tightly fitting clear tray to encase the [Figure 1] or trays as a means of sequentially straightening teeth. Here is how Dr. Nahoum described his process: teeth has evolved significantly to where, today, the technique “The appliance may also be fabricated to move teeth. Anterior has been adopted by many dentists wanting to provide some spaces can be closed and minor rotations can be corrected. To do this, degree of orthodontic correction for their patients. Once lim- a plaster cast is made. The teeth are sawed off the cast with a jeweler’s ited to correcting small amounts of crowding or spaces in fully saw or a fissure bur. The teeth are then repositioned on the model erupted dentitions, it is now utilized by experienced clinicians with wax. The contour appliance is vacuum formed over the altered in a broad spectrum of the comprehensive treatment of com- (waxed) model. The excess is cut away with a razor and the appliance plex malocclusions. This course will trace that evolution and is removed from the cast, cleaned and inserted into the mouth.” document the validity of using clear aligners in contemporary Figure 2. Positioner setup orthodontic treatment.

Figure 1. Clear aligners

Lab set-up for tooth positioner (slide 25). Digital image. Retention 1 Certified Fixed Orthodontic Courses by Indian Dental Academy. Accessed March 4, 2017. https://www.slideshare.net/indiandentalacademy/ In the Beginning retention1. Without question, in addition to cost and discomfort, esthetics are a major factor when patients consider straightening their Figure 3. Positioner teeth with braces. Advances in adhesives and metallurgy have made orthodontic treatment with metal and ceramic braces somewhat more attractive, but many patients still resist having braces attached to their teeth. The concept of clear, removable aligners to straighten teeth has offered reluctant patients an alternative to the traditional braces they did not want to wear. In the 1940s, Dr. H. D. Kesling developed a process1 in which he removed the teeth from stone models, reset them in wax back on the original models in an ideal alignment [Figure 2], and fabricated a rubber mouthguard-type of mold for the patient’s upper and lower teeth to fit into,©PENNWELL®2017 called a “positioner” [Figure 3]. With adequate wear, the patient’s teeth would move Dentsply OrthoLab Dental Positioner." Digital image. Dentsply Ortholab. into the ideal alignment designed on the reset models. Later, in 2017. Accessed March 3, 2017. http://www.dentsplyortholab.com/pub/ 1959, Dr. Henry Nahoum built upon Dr. Kesling’s concept of Products-Dental-Positioners.

2 www.DentalAcademyOfCE.com Figure 4. Elements of the first vacuum former tal models in a manner that allows the teeth to be straightened in a sequential order from “crooked” to “straight” [Figure 5]. The software is manipulated by a technician, or the doctor in some cases, to design a treatment plan according to the doctor’s provided prescription. The parameters and velocity of the tooth movements are uniquely calculated for each tooth depend- ing upon the crown shape, root size, and position in the arch. These metrics, designed for each sequential step, or stage, are engineered into the software, but may be over-ridden, within reasonable limits, by the doctor’s directions. The software will display the digital treatment plan in both static and animated modes [Figure 6]. There are a variety of fea- tures included in the software to enhance the reviewer’s analysis In 1997, two graduate students founded a company which of the proposed plan, including: multi-axis rotation of the digital introduced clear aligners to the mass market, revolutionizing model, measurement tools, tooth size/space analysis, etc. the way doctors considered esthetics in orthodontic treatment. After a critical review of the animated treatment plan, the Their business model incorporated mass production, digital doctor can approve the plan to initiate the aligner fabrication, computer imaging, unconventional marketing directly to the provide instructions to the technician to revise the proposed public, and a new paradigm that challenged doctors' training plan, or decline the plan and withdraw the submission of the and experience. During the early 2000s, dentists were intro- case without further obligation. duced to a technique defined by mass-customization, digital The animated treatment plan can be shared with colleagues, computer imaging, unconventional marketing directly to the family, and friends via the internet on smartphones, laptops, and public, and a new paradigm that challenged their training and remote desktops, serving as an excellent communication tool. experience. Wanting to step slowly into this new treatment mo- Figure 5. Software dality with unproven results, clinicians were advised to utilize clear aligners only for patients with small amounts of crowding or spaces in dentitions with second permanent molars fully erupted. With increasing experience, doctors impatient with these “advised” restrictions began expanding the scope of “what is possible” with the new appliance, and are now treat- ing patients presenting with moderate to severe crowding, deep bites, constricted arches, and other complex corrections, even four bicuspid extraction cases. Modern clear aligner therapy requires: • specially engineered software for strategically relocating teeth on the digital models in a sequential order; • plastic material uniquely formulated for optimum aligner performance; • a rich set of features to aid the aligners in moving teeth (i.e., the animated setups, optional additions of composite Figure 6. Treatment setup to enhance function of the aligners, measurement and analytical tools, and the utilization of auxiliary devices) and, • most importantly, the doctor’s level of training and experi- ence in tooth movement, orthodontic treatment principles, and utilization of clear aligners.

There’s More Involved Than Just Clear Trays ©PENNWELL®2017 The Software At the core of the ability for aligners to be©PENNWELL®2017 effectively used for orthodontic corrections lies digital 3-D dental imaging and a software program3 designed to rearrange the teeth on the digi-

www.DentalAcademyOfCE.com 3 The Plastic Material The Use of Auxiliaries The choice of which plastic material to use for a series of align- As with traditional fixed braces, successful orthodontic treatment ers is made by the manufacturer, not the doctor ordering them. with clear aligners often requires , temporary Each aligner provider has their own reasons for choosing which devices (TADs), expanders, or even limited fixed braces to supple- plastic product they will use based upon the combination of ment the tooth movement provided by the aligners. characteristics and properties they want to promote. The plas- Elastics used for class II or class III traction can be attached to tic’s clarity, durability, stain resistance, rigidity, flexibility, and buttons bonded to the facial surface of cuspids and molars [Figure use of single or multiple layers during thermoforming are all 8], or, as an alternative technique, attached to slits cut out of the properties that contribute to the definition of a manufacturer’s aligner margin next to the cuspids and molars [Figure 9]. When aligners’ characteristics. The reality is that there is not a plastic the elastic is attached to a button bonded on the tooth, the full product rated superior for all of these properties, so doctors force of the elastic is transmitted to the tooth and related alveolar must decide which characteristics they value most when select- structure. If the elastic is connected to the aligner in some manner, ing the provider for their aligners. the full force of the elastic is dissipated throughout the full arch via Studies4,8 have shown that when used to deliver tooth- the aligners, minimizing the desired effect of the elastic traction. movement forces, thermoplastic materials exhibit stress relief, or Those clinicians preferring the attachment of the elastic onto “creep”. This occurs for the duration of their use, adversely af- the aligner feel it saves them chair time to have the manufacturer fecting the mechanical properties. This phenomenon is the result provide the elastic cutouts. Without knowing exactly when to of the plastic’s inherent elasticity and will vary from one material start or stop the application of the elastics, the patient must accept to another. Some providers desire a stiffer, less elastic material the presence of the slits in all their aligner stages, unless there is a that will reduce the aligner creep, while others prefer a multilayer midcourse correction made without the slits. These clinicians must material that gives the patient a softer, more comfortable fit.5 closely observe for any aligner deformation or displacement caused by the elastic forces; even a small displacement of the aligner mate- The “Buttons” rial away from the facial surface of the cuspid reduces the aligner The software technicians frequently suggest the placement of effect on that tooth. If the elastic force is too heavy, the whole small dollops of tooth-colored composite material on certain teeth aligner can be pulled down off the teeth. which will be encased in a tiny “bubble” in the aligners [Figure 7]. Clinicians who prefer to attach the elastic to a button on the Whether they are called “engagers,” “attachments,” or “buttons,” tooth believe the chair time required to initially bond and remove these are simply small amounts of composite material bonded the buttons and modify the aligners during the elastic wear is mini- to the facial or lingual surface of the tooth. The number, various mal and offset by the increased effectiveness of the technique, i.e., shapes, and location placements are determined by the software shorter time required for the patient to wear the elastic. technician and approved or modified by the doctor. While widely Although not always highly predictable,7 aligners can accom- believed to significantly improve the efficacy of tooth movement, plish about 3-4 mm of dental arch expansion. If skeletal expansion there are no published reports that verify this belief, or that one is advised, some type of appliance should be used to accomplish shape is more effective than another. However, there are published adequate skeletal expansion prior to taking the impressions or reports6 supporting the claim that the most valid usage of these scans for the aligners. A transpalatal appliance of some design is items is for increasing the retention of the aligner. Until more cred- inserted to hold the achieved expansion until the delivery of the ible research is published, the actual effectiveness of these common first aligners. An aligner with full palatal coverage may be used additions to the aligner system must remain theoretical. as a trial aligner to get the patient used to wearing the removable device. Expanding the underlying skeletal foundation increases Figure 7. Engagers the stability of the dental expansion and other movements created by the aligners.

Figure 8. Elastics with buttons

Elastic auxilliaries with attachments. Digital image. Heartful Kyosei Dental Blog. October 23, 2014. Accessed March 4, 2017. http://www. ©PENNWELL®2017heartful-kyosei.com/blog/ doctor/2014/10/.

4 www.DentalAcademyOfCE.com Figure 9. Elastics with cutouts all of the reasonable treatment alternatives to the patient, but the patient should have the final say in making the treatment decision. Studies14 have shown that the public’s satisfaction with clear align- ers to correct their malocclusion is growing and driving dentists to gain proficiency in this novel treatment modality.

From Easy to Difficult, It’s All Possible Regardless of the brand of aligners chosen or the level of experience treating with fixed braces, one new to treatment with clear aligners is well advised to choose “easy” cases as their first. This category will include minor crowding or spaces, minimal rotations (less than 5°), and exclude skeletal imbalances, anterior-posterior discrepan- cies, extrusions, extractions, and short or very small teeth. These Glaser, Barry J., DMD. Elastic auxilliaries with cutouts. Digital image. cases will usually require five or six (or fewer) sets of aligners (set = An Everyday Treatment. April 15, 2015. Accessed March 4, 2017. http:// one upper and one lower aligner) [Figures 10 and 11]. www.orthodonticproductsonline.com/2015/04/everyday-treatment/. “Moderate” cases represent the typical classification for the practitioner looking to expand their clinical experience with clear The Dental Profession’s Acceptance aligners. Moderate crowding and spaces, need for dental expansion Every day, advances in technology affect the way we live and (as contrasted to skeletal expansion), deep bites, single lower anterior work. Indeed, advances in clear aligner technology have changed extraction, and midline alignment are examples of typical correc- orthodontics forever … but not without some controversy. tions that can be made with this level of treatment. These cases will Originally offered only to orthodontic specialists, this use seven to twelve sets (or fewer) of aligners [Figures 12 and 13]. revolutionary technology now provides diagnostic assistance, a Only the dentists who are sufficiently experienced with clear prediction of the designed treatment result, and a prefabricated aligner treatment, trained in the diagnosis of orthodontic maloc- appliance to achieve the projected goal to any licensed dentist. clusions, and knowledgeable of tooth movement principles should While most orthodontists were reluctant to embrace the new attempt to correct the “difficult” cases. Multiple extractions, pre- method for straightening teeth without braces attached to the surgery alignment, severe crowding or deep bite, and skeletal imbal- teeth, general dentists without orthodontic training or educa- ances should all be considered difficult to correct with clear aligners. tion recognized the clear aligners as a pathway to expanding the This degree of experience is not only helpful in creating a good scope of care they could offer to their patients. digital treatment plan, but it is absolutely necessary for the proper Today, the dental profession as a whole promotes the popu- monitoring and treatment management demanded by these harder lar concept of “” with the use of clear align- cases [Figures 14 and 15]. ers, however, often overlooking the long-standing standards for an optimal or ideal occlusion as it is defined during extended Figure 10. Easy before training and education.9 The evidence supporting the clinical effectiveness of orth- odontic treatment and predictability14 continues to build. Once thought to be beyond the control of clear aligners, molar distal- ization and extraction space closure are no longer doubted to be within the scope of achievable successful treatment.10,11,12 Periodontists are also singing the praises of treating peri- odontally threatened patients with clear aligners due to the controlled delivery of forces and the patient’s ability to better respond to periodontal treatment that can often run concurrent Figure 11. Easy after with the ongoing orthodontic treatment.13

The Public’s Awareness and Demand The mass marketing of clear aligners to consumers via TV, social media, publications, and other media has motivated patients to seek orthodontic correction they never would have considered if fixed braces were their only option. Clear aligners often offer the consumer the option to improve their smile by only straightening their upper front ©PENNWELL®2017teeth. It is the dentist’s responsibility to explain

www.DentalAcademyOfCE.com 5 Figure 12. Moderate before in the setup. With the proper education, training, and experi- ence, clinicians can expect to achieve optimum treatment results in a broad spectrum of malocclusions with clear aligners.

References 1. Kesling HD. The philosophy of the tooth positioning appliance. American Journal of Orthodontics and Oral Surgery. 1945;31, Issue 6, pages 297-304. 2. Nahoum H. The vacuum formed dental contour appliance. New York State Dental Journal. 1964;30, Issue 9, pages 385-390. Figure 13. Moderate after 3. Levrini L, Tieghi G, Bini V. Invisalign ClinCheck and the aesthetic digital smile design protocol. J Clin Orthod. 2015 Aug;49(8):518-24. 4. Gerard BT, Teske L, Eliades G, Zinelis S, Eliades T. Do the mechanical and chemical properties of InvisalignTM appliances change after use? A retrieval analysis. Eur J Orthod. 2016 Feb;38(1):27-31. 5. Bräscher AK, Zuran D, Feldmann RE Jr, Benrath J. Patient survey on Invisalign® treatment comparing the SmartTrack® material to the previous aligner material. J Orofac Orthop. 2016 Nov;77(6):432-438. Figure 14. Difficult before 6. Cowley D, O’Toole B, Mah J. The effect of gingival- margin design on the retention of thermoformed aligners. J Clin Orthod. Volume 46: Number 11: Pages (697-702) 2012. 7. Solano-Mendoza B, Sonnenberg B, Solano-Reina E, Iglesias-Linares A. How effective is the Invisalign® system in expansion movement with Ex30' aligners? Clin Oral Investig. 2016 Jul 19. 8. Lombardo L, Martines E, Mazzanti V, Arreghini A, Mollica F, Siciliani G. Stress relaxation properties of four orthodontic aligner materials: A 24-hour in vitro study. Angle Orthod. 2017 Jan;87(1):11-18. Figure 15. Difficult After 9. Heath EM, English JD, Johnson CD, Swearingen EB, Akyalcin S. Perceptions of orthodontic case complexity among orthodontists, general practitioners, orthodontic residents, and dental students. Am J Orthod Dentofacial Orthop. 2017 Feb;151(2):335-341. 10. Ravera S, Castroflorio T, Garino F, Daher S, Cugliari G, Deregibus A. Maxillary with aligners in adult patients: a multicenter retrospective study. Prog Orthod. 2016; 17:12. 11. Fischer K. Invisalign treatment of dental class II Conclusion malocclusions without auxiliaries. J Clin Orthod. 2010 Clear aligners for correcting complex orthodontic problems Nov;44(11):665-72. have been available to dentists for nearly two decades, with their 12. Li W, Wang S, Zhang Y. The effectiveness of the acceptance and utilization growing significantly every year. Invisalign appliance in extraction cases using the ABO However, many still do not appreciate or understand the com- model grading system: a multicenter randomized plexities involved in using clear trays to sequentially move teeth controlled trial. Int J Clin Exp Med. 2015 May in comprehensive orthodontic corrections, allowing them to scan 15;8(5):8276-82. teeth, request a©PENNWELL®2017 digital setup of the treatment plan, dispense the 13. Levrini L, Mangano A, Montanari P, Margherini S, aligners to the patient, and expect the treatment result forecasted Caprioglio A, Abbate GM. Periodontal health status

6 www.DentalAcademyOfCE.com in patients treated with the Invisalign® system and Author Profile fixed orthodontic appliances: A 3 months clinical ClearCorrect™ clinical advisor Ken Fischer, DDS, received his and microbiological evaluation. Eur J Dent. 2015 Jul- orthodontic certificate from UCLA in 1975 and has maintained Sep;9(3):404-10. his private practice of orthodontics in Villa Park, California, since 14. Krieger E, Seiferth J, Marinello I, Jung BA, Wriedt S, that time. He was an early adopter of clear aligner treatment in Jacobs C, Wehrbein H. Invisalign® treatment in the 2000 and has treated nearly 1,500 patients with clear aligners. He anterior region: were the predicted tooth movements has shared his treatment experiences with both domestic and inter- achieved? J Orofac Orthop. 2012 Sep;73(5):365-76. national audiences, published a number of articles regarding clear 15. Azaripour A, Weusmann J, Mahmoodi B, Peppas D, aligners, and has also served as a clinical advisor for Invisalign™. Gerhold-Ay A, Van Noorden CJ, Willershausen B. Braces versus Invisalign®: gingival parameters and Author Disclosure patients’ satisfaction during treatment: a cross-sectional Ken Fischer, DDS, is a clinical advisor for the sponsors of the study. BMC Oral Health. 2015 Jun 24; 15:69. unrestricted educational grant for this course.

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Questions

1. In the early days of using a 5. The first person to create a process 9. Which of the following is not a sequential series of clear aligners to for vacuum-forming a clear plastic key component of the clear aligner straighten teeth, the technique was tray over teeth was: system? limited to: a. Henry Ford a. Special engineered software a. Limited amounts of crowding b. Thomas Edison b. Uniquely formulated plastic material b. Small spaces c. Isaac Singer c. A rich set of features for aiding the treatment c. Dentitions with fully-erupted second molars d. Henry Nahoum setup design d. All of the above 6. The vacuum used to suck the plastic d. A complex and complicated screening process for selecting qualified patients 2. Today, clear aligners are not recom- down over the dental model was mended for treatment of: created by: 10. Modern clear aligner therapy a. A broad spectrum of complex malocclusions a. The inventor’s mother’s vacuum cleaner requires: b. Deciduous dentitions b. The inventor sucking vigorously on a long tube a. Orthodontic treatment principles and c. Extraction cases c. A bellows operated by the inventor’s son techniques d. Presurgery dental alignment d. A miniature water pump b. Plastic uniquely formulated for optimum aligner 3. In the 1940s, the technique of 7. The cofounders who introduced clear performance resetting teeth on a model for the fab- aligners to the mass market were: rication of an appliance to straighten c. Specially engineered software. those teeth was developed by: a. Public activists at Berkley d. All of the above. b. Graduate students a. Robert M. Ricketts 11. The core of the aligners’ ability to b. Ron M. Roncone c. In their sixth year at a junior college d. UCLA cheerleaders effectively make orthodontic correc- c. H. D. Kesling tions is: d. Edward H. Angle 8. The new technique of clear aligners a. The number of attachments it requires. 4. The appliance referenced above is introduced to dentists in the early b. The company from which the doctor buys known as a: 2000s was innovating with: the aligners a. Herbst a. Mass-customization c. 3D dental imaging and a software program b. Frankel ©PENNWELL®2017b. Digital computer imaging engineered to sequentially reposition teeth c. Positioner c. Unconventional marketing directly to the public d. The treatment documentation that is shipped d. Bionator d. All of the above with each set of aligners

www.DentalAcademyOfCE.com 7 Questions (continued)

12. Which of the following would the 19. Which of the following is not 26. The public’s satisfaction and doctor not use as a determinate of the considered as an auxiliary in clear demand for clear aligners is: tooth’s velocity during movement? aligner treatment? a. Nonexistent a. Crown shape a. Expanders b. Decreasing b. Root size b. TADs c. Unchanged c. Age of the patient c. Elastics d. Growing d. Tooth’s location in the arch d. Retainers 13. After a doctor reviews a techni- 20. Elastics can be utilized with clear 27. A clinician new to clear aligner cian’s recommended treatment aligners by wearing them: treatment should begin their experi- plan via the setup, which of the a. From buttons bonded directly to the teeth ence with: following is not one of his/her b. From slits cut into the gingival margin of the a. Easy cases aligners b. Moderate cases options? c. From TADs placed in the gingiva above the c. Difficult cases a. Decline the plan and terminate the treatment aligner margin b. Revise the plan and request another setup d. All of the above d. Aligners combined with traditional braces c. Approve the plan and begin fabrication of the aligners 21. The clinicians preferring to attach 28. Easy cases are characterized by: d. Request that the proposed plan be transferred to elastics directly to the slits in the a. Skeletal imbalances another doctor aligner believe: b. Extractions 14. The least desirable property a. This technique will provide the best possible c. Minor crowding or spaces characteristic of aligner material is: treatment result d. Anterior-posterior discrepancies a. Clarity b. This technique does not require the patient’s compliance 29. Moderate cases include: b. Roughness a. 1-5 sets of aligners c. Strength c. This technique saves the doctor chair time b. 6-12 sets of aligners d. Stain resistance d. This technique is proven to be the most effective way to use elastics c. An unlimited number of aligners 15. The stress relief exhibited by all 22. Most clinicians believe the dental d. None of the above aligner plastic materials is known as: a. Creep arch can be expanded with clear 30. In order to treat difficult cases, a b. Crawl aligners: doctor does not need to be knowl- a. Not at all c. Scoot edgeable or proficient in: d. Relaxation b. 1-2 mm c. 3-4 mm a. Tooth movement principles 16. The small dollops of composite d. 5 mm or more b. Diagnosis and treatment planning material bonded on the tooth are 23. Using clear aligners to straighten c. Proper monitoring and treatment management known as: d. Placing TADs a. Engagers teeth has changed orthodontics b. Attachments forever due to: c. Buttons a. Clear plastic materials d. All of the above b. Technology c. Clinicians’ acceptance 17. The primary effectiveness of a d. Trained technicians button is to improve: a. Tooth movements 24. The prescription of clear aligners b. Aligner retention for comprehensive orthodontic c. Movement velocity treatment is available to: d. Patient compliance a. Dental hygienists b. Lab technicians 18. Which of the following is not a true c. Any licensed dentist statement regarding engagers? d. All of the above a. They must be used in every case b. The doctor must ultimately approve or modify 25. The public’s awareness of clear each one aligners has been heightened by: c. There is no research to validate that one shape is a. Mass marketing directly to the public more effective than another b. Low treatment fees d. There is no research©PENNWELL®2017 to validate that engagers c. Short treatment times significantly improve tooth movement. d. Radio ads

8 www.DentalAcademyOfCE.com Notes

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www.DentalAcademyOfCE.com 9 Notes

©PENNWELL®2017

10 www.DentalAcademyOfCE.com INSTANT EXAM CODE 15167 ANSWER SHEET Orthodontic Treatment with Clear Aligners

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Requirements for successful completion of the course and to obtain dental continuing education credits: 1) Read the entire course. 2) Complete all information above. 3) Complete answer sheets in either pen or pencil. 4) Mark only one answer for each question. 5) A score of 70% on this test will earn you 3 CE credits. 6) Complete the Course Evaluation below. 7) Make check payable to PennWell Corp. For Questions Call 800-633-1681 If not taking online, mail completed answer sheet to Educational Objectives PennWell Corp. Attn: Dental Division, 1. Be familiar with the components of the clear aligner system; 1421 S. Sheridan Rd., Tulsa, OK, 74112 2. Understand that clear aligners are capable of treating a broad spectrum of malocclusion; and or fax to: 918-831-9804 3. Appreciate the complexities of mastering orthodontic treatment with clear aligners. For IMMEDIATE results, go to www.DentalAcademyOfCE.com to take tests online. Course Evaluation INSTANT EXAM CODE 15167 Answer sheets can be faxed with credit card payment to 1. Were the individual course objectives met? 918-831-9804. Objective #1: Yes No Objective #2: Yes No  Payment of $59.00 is enclosed. (Checks and credit cards are accepted.) Objective #3: Yes No If paying by credit card, please complete the Please evaluate this course by responding to the following statements, using a scale of Excellent = 5 to Poor = 0. following: MC Visa AmEx Discover 2. To what extent were the course objectives accomplished overall? 5 4 3 2 1 0 Acct. Number: ______Exp. Date: ______3. Please rate your personal mastery of the course objectives. 5 4 3 2 1 0 Charges on your statement will show up as PennWell 4. How would you rate the objectives and educational methods? 5 4 3 2 1 0 5. How do you rate the author’s grasp of the topic? 5 4 3 2 1 0 1. 16. 6. Please rate the instructor’s effectiveness. 5 4 3 2 1 0 2. 17. 7. Was the overall administration of the course effective? 5 4 3 2 1 0 3. 18. 8. Please rate the usefulness and clinical applicability of this course. 5 4 3 2 1 0 4. 19. 9. Please rate the usefulness of the supplemental webliography. 5 4 3 2 1 0 5. 20. 10. Do you feel that the references were adequate? Yes No 6. 21. 11. Would you participate in a similar program on a different topic? Yes No 7. 22. 8. 23. 12. If any of the continuing education questions were unclear or ambiguous, please list them. ______9. 24. 10. 25. 13. Was there any subject matter you found confusing? Please describe. ______11. 26. 12. 27. 14. How long did it take you to complete this course? ______13. 28. 14. 29. 15. What additional continuing dental education topics would you like to see? 15. 30. ______AGD Code 377 PLEASE PHOTOCOPY ANSWER SHEET FOR ADDITIONAL PARTICIPANTS. COURSE EVALUATION and PARTICIPANT FEEDBACK PROVIDER INFORMATION RECORD KEEPING We encourage participant feedback pertaining to all courses. Please be sure to complete the survey included PennWell is an ADA CERP Recognized Provider. ADA CERP is a service of the American Dental association PennWell maintains records of your successful completion of any exam for a minimum of six years. Please with the course. Please e-mail all questions to: [email protected]. to assist dental professionals in identifying quality providers of continuing dental education. ADA CERP contact our offices for a copy of your continuing education credits report. This report, which will list all does not approve or endorse individual courses or instructors, not does it imply acceptance of credit hours credits earned to date, will be generated and mailed to you within five business days of receipt. INSTRUCTIONS by boards of dentistry. All questions should have only one answer. Grading of this examination is done manually. Participants will Completing a single continuing education course does not provide enough information to give the receive confirmation of passing by receipt of a verification form. Verification of Participation forms will be Concerns or complaints about a CE Provider may be directed to the provider or to ADA CERP ar www.ada. participant the feeling that s/he is an expert in the field related to the course topic. It is a combination of mailed within two weeks after taking an examination. org/cotocerp/ many educational courses and clinical experience that allows the participant to develop skills and expertise. COURSE CREDITS/COST The PennWell Corporation is designated as an Approved PACE Program Provider by the Academy of General CANCELLATION/REFUND POLICY All participants scoring at least 70% on the examination will receive a verification form verifying 3 CE Dentistry. The formal continuing dental education programs of this program provider are accepted by the Any participant who is not 100% satisfied with this course can request a full refund by contacting PennWell in writing. credits. The formal continuing education program of this sponsor is accepted by the AGD for Fellowship/ AGD for Fellowship, Mastership and membership maintenance credit. Approval does not imply acceptance Mastership credit. Please contact PennWell©PENNWELL®2017 for current term of acceptance. Participants are urged to contact by a state or provincial board of dentistry or AGD endorsement. The current term of approval extends from IMAGE AUTHENTICITY their state dental boards for continuing education requirements. PennWell is a California Provider. The (11/1/2015) to (10/31/2019) Provider ID# 320452 The images provided and included in this course have not been altered. California Provider number is 4527. The cost for courses ranges from $20.00 to $110.00. © 2017 by the Academy of Dental Therapeutics and Stomatology, a division of PennWell OTCA0617DIG

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