MetLife designates this activity for 1.0 continuing education credit for the review of this Quality Resource Guide and successful Quality Resource Guide completion of the post test. THIRD EDITION Management of and Skeletal Problems

2. Dental/Occlusal Problems Author Acknowledgements Educational Objectives Several dental and/or occlusal conditions may Mitchell Lipp, DDS Clinical Associate Professor Following this unit of instruction, the practitioner influence orthodontic diagnosis and prognosis, or the Director, Pre-Doctoral Courses in Clinical Orthodontics should be able to: outcome of orthodontic therapy. The factors are listed Coordinator, Curriculum for Undergraduate under Category 2, Table 1. It is important that dentists 1.  Evaluate patients who present with Orthodontics recognize these problems, record them and factor Department of Orthodontics malocclusion and skeletal problems. them into their treatment plans. New York University - College of 2. Recognize and record oral conditions that may New York, New York Some of the factors listed in Category 2, Table 1 may be Dr. Lipp has no relevant financial influence orthodontic diagnosis, prognosis or relationships to disclose. the outcome of therapy. a result of abnormal dental development and/or tooth The following commentary highlights eruption. During the clinical intra-oral examination 3.  Distinguish severe conditions including fundamental and commonly accepted of the patient, the dentist should regularly identify practices on the subject matter. The overbite, overjet, open bite, crowding, spacing information is intended as a general overview the erupted teeth in the mouth and compare this and/or occlusal interferences that may trigger and is for educational purposes only. This information to the patient’s dental and chronological information does not constitute legal advice, referral to a specialist. which can only be provided by an attorney. age. If abnormalities are detected, radiographs can © Metropolitan Life Insurance Company, determine: New York, NY. All materials subject to this copyright may be photocopied for the Introduction • Impacted teeth noncommercial purpose of scientific or educational advancement. • Developing teeth that are in poor positions The dentist is responsible for the well-being of Originallypublished March 2009. Updated the patient’s oral, perioral, and facial structures. and are at risk for impaction and revised June 2012 and September 2015. Expiration date: December 2018. This guide describes the clinical aspects that every • Missing teeth The content of this Guide is subject to dentist should consider when assessing a patient change as new scientific information • Supernumerary teeth becomes available. with orthodontic problems and when managing patients with malocclusion and/or skeletal problems. • Over retention of primary teeth • Premature loss of primary teeth MetLife is an ADA CERP Recognized Provider. 1. Patient Concerns ADA CERP is a service of the American Dental • Ankylosed teeth Association to assist dental professionals Eliciting the patient’s esthetic concerns is an important in identifying quality providers of continuing first step in considering a need for orthodontic care. Other occlusal, skeletal and/or functional conditions dental education. ADA CERP does not approve Most patients who benefit from orthodontic care should be recognized as potential risk factors that or endorse individual courses or instructors, nor does it imply acceptance of credit hours by (or orthognathic surgery) do not have disease in the could lead to a compromise of health and function boards of dentistry. traditional sense. A sometimes-overlooked component of the initial patient interview is recognizing and Concerns or complaints about a CE provider may be directed to the provider or to ADA of the initial patient interview is recognizing and (Category 3, Table 1). Some of these conditions have CERP at www.ada.org/goto/cerp. understanding the patient’s esthetic perceptions. The threshold values (a level that is considered to have Accepted Program Provider FAGD/MAGD dentist should begin by interviewing the patient. an impact on health and/or function). A summary Credit 11/01/12 - 12/31/16 Questions like, “Do you like the way your teeth look?” of thresholds generally accepted to identify SEVERE Address comments to: [email protected] or “Do you like your smile?” are effective starting occlusal conditions is found in Table 2. Recognizing a MetLife Dental points. The process should end with a notation in the severe condition is important, as it should trigger the Quality Initiatives Program 501 US Highway 22 dental record describing the patient’s concerns. consideration of referral to a specialist. Bridgewater, NJ 08807

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Table 1 - Orthodontic Considerations 3. Occlusal Risk Factors D. Dental Crowding (5+ mm) (Threshold) The arch perimeter is measured from the mesial 1. Patient Concerns A. Overbite (100% or if the lower anterior of the first molars directly from diagnostic casts. 2. Dental/Occlusal Problems teeth contact palatal tissue) The measurement is broken down to a series of a. Malocclusion Overbite is defined as the percentage of line segments that best describe the idealized b. Tooth malposition associated with dental vertical overlap of the upper incisors over the arch form. Overlapping contacts are measured or periodontal pathology or dysfunction lower incisors, and is measured intra-orally or (in mm) as areas of crowding. Any condition of c. Tooth malposition adjacent to an from study casts articulated in the maximum crowding above 5 millimeters in a given arch extraction site that could affect optimal intercuspation position. 100% overbite exists restorative rehabilitation is considered severe. Crowding can also be d. Tooth malposition related to supra if the maxillary incisors completely overlap considered severe if an individual tooth has eruption [hyperocclusion] the mandibular incisors when the maxilla and slipped past the proximal contact more than 2 e. Tooth malposition related to trauma mandible are in maximum intercuspation. mm with the adjacent tooth or if it is locked out f. Impacted teeth of the arch. g. Developing teeth that are in poor B. Overject (5+ mm) positions and are at risk for impaction Overjet is the distance (in mm) between the E. Spacing (5+ mm) h. Missing teeth facial surface of the mandibular incisors and the i. Supernumerary teeth maxillary incisors measured at the incisal edge The arch perimeter is measured from the mesial j. Disturbances of dental development and of the most labial tooth. Overjet is measured of the first molars directly from diagnostic casts. eruption intra-orally or from study casts articulated in The measurement is broken down to a series of k. Disturbances of tooth eruption line segments that best describe the idealized l. Over retention of primary teeth the maximum intercuspation position. Assuming m. Premature loss of primary teeth that the maxillary incisors overlap the mandibular arch form. n. Ankylosed teeth incisors, overjet is a positive number. If, however, Open contact areas are measured as areas of o. Tooth malposition related to function the mandibular incisors are in front of the maxillary spacing. When the sum of space is greater than (see category #5) incisors, a condition known as, “anterior crossbite,” 5 millimeters in a given arch, the condition is overjet is expressed as a negative number. 3. Occlusal Risk Factors considered to be severe. When an arch has both a. Overbite (100%) C. Open Bite (Any degree of open bite) overlapping contacts and open contacts, the b. Overjet (Severe) Open bite exists when there is no vertical overlap dentist should first calculate the overall amount c. Open bite of the upper teeth over the lower teeth in of spacing or crowding in the arch, then itemize d. Dental crowding (Severe) maximum intercuspation. The millimeter distance areas of particular concern that may affect e. Dental spacing (Severe) of separation between the incisal edges (anterior) treatment. f. Occlusal interferences resulting in or occlusal surfaces (posterior) is the amount mandibular functional shifts of open bite. Open bite can be measured intra- In the transitional dentition, the “leeway space” should be considered when evaluating spacing/ 4. Skeletal Risk Factors orally or from study casts articulated in the a. Skeletal Class II, Class III maximum intercuspation position. This condition crowding. The “leeway space” is the extra space b. Facial asymmetry potentially compromises the patient’s ability to available when the wider primary posterior teeth c. Excess or deficient lower facial height incise or chew food. Any condition that results are exfoliated and replaced by the narrower d. Skeletal Open Bite (hyperdivergent) in masticatory insufficiency is critical for the permanent teeth. As a clinical guideline, 1mm per e. Skeletal Deep Bite (hypodivergent) practitioner to recognize. quadrant should be considered in the maxillary

5. Functional Risk Factors Table 2 - Threshold Values a. Labial incompetence b. Oral Habits (e.g. finger or lip sucking) Condition Evaluation Method Threshold for SEVERE c. Abnormal swallow (e.g. tongue thrusting) % vertical overlap of the upper 100% (or impingement on palatal d. Abnormal breathing (e.g. mouth breathing) Overbite incisors over the lower incisors mucosa) e. Bruxism Incisal edge of most facial f. Clenching Overjet maxillary incisor to most facial 5+ mm mandibular incisor 6. Problem List and Treatment Objectives 5+ mm (spacing) Crowding/Spacing Sum of overlapping contacts (negative) and open contacts 7. Treatment Plan (per arch) (positive) 5+ mm (crowding)

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arch and 2mm per quadrant in the mandibular • Lateral Shift: The dentist should evaluate the (Figure 2). Recognizing malocclusion begins with arch as the “leeway space”. Normally, this space maxillary dental midline and the mandibular Angle’s classic descriptions (Figure 3). Angle’s will be lost after exfoliation of the primary teeth dental midline in the maximum intercuspation scheme is useful in identifying problems in the due to mesial migration of the permanent molars. position and in a mouth open position. If the sagittal [anterior-posterior] plane. The dentist However, if properly managed, this space can be mandibular midline relationship changes from used to resolve situations of borderline crowding. when the mandible moves from an open to Figure 1 a closed position, there is likely a lateral It is also important to look at radiographs mandibular functional shift. If the mandibular when evaluating spacing or crowding. If teeth midline is off to one side and that is consistent are impacted or at risk for impaction, due to with the side that appears to be in unilateral insufficient space for eruption, the condition crossbite, it is likely that there is a functional is best described as, “crowding” regardless of shift of the mandible (Figure 1). clinical presentation (open contacts). When evaluating “subdivision” or asymmetrical Left side functional posterior crossbite. F. Occlusal Interferences/Mandibular , the dentist should consider if Functional Shifts the mandibular midline shift correlates with the Figure 2 The dentist should describe tooth misalignment malocclusion. A functional mandibular shift may using standardized terminology. A description be a contributing factor to the malocclusion. should include the tooth or group of teeth, the type of problem, direction and magnitude of 4. Skeletal Conditions misalignment. In the frontal view one can detect Classification of is based on the posterior problems of tooth angulation (mesial-distal tilt) teeth and canines in maximum intercuspation. In and vertical position (up or down). In the sagittal many clinical situations the occlusion of the molars view one can detect problems of inclination alone gives inadequate information. The first step (facial-lingual tilt). In the occlusal view, one can in the process of accurately analyzing the occlusion detect rotational problems. is comfort in recognizing normal occlusion Sample descriptions of misaligned teeth are as follows: Figure 3 • #8 is angulated mesially 5° • #8 is intruded 5 mm • #8 is rotated 5° distolingually • #8 is retroclined 5° Misaligned teeth or groups of teeth may create interferences in the occlusion. The patient accommodates by shifting the mandible to avoid the interferences and establishes an alternative maximum intercuspation position. Functional shifts are noted during the clinical evaluation of the patient.

• Anterior Shift: If a patient occludes with a complete anterior crossbite, the patient may have a skeletal Class III problem or occlusal interferences resulting in a forward shift to the mandible. If the patient can bring his/her teeth edge to edge, he/she most likely does not have a skeletal problem (this condition is often called, “Pseudo Class III”).

www.metdental.com Page 3 Quality Resource Guide – Management of Malocclusion and Skeletal Problems 3rd Edition should use the occlusion as the first step of A. Class II or Class III (Profile View) lower facial height is often associated with identifying sagittal plane skeletal problems since The dentist can evaluate abnormal profile a hyperdivergent growth pattern. In this associations between malocclusion and skeletal convexity (Skeletal Class II) or concavity (Class condition, the mandible rotates downward and relationships often exist: III) by examining the relationship between: the backward during growth. Severe expressions of most anterior portion of the forehead, the base hyperdivergence will present as a skeletal open Occlusion Skeletal Relationship of the nose where the upper lip begins, and the bite (the skeletal relationship is a contributing ...... most anterior part of the chin (Figure 4). factor for the open bite). The diagnosis of this condition should be confirmed by cephalometric Class I Normal Occlusion Class I Skeletal B. Facial Asymmetry (Facial View) analysis...... A degree of facial asymmetry is “normal”. Gross Class I Malocclusion Class I Skeletal facial asymmetry is a subjective term, but the The diagnostic “gold standard,” is whether the ...... dentist can generally determine its presence by condition is clinically significant. It is critical Class II Division 1 Class II Skeletal looking at the patient’s face and relating the chin to recognize this condition if a hyperdivergent Malocclusion to the facial midline (Figure 5). pattern manifests in extreme facial disproportion (excessive lower facial height, unaesthetic ...... C. Excessive/Diminshed Lower Anterior vertical maxillary excess [VME], or contributes to Facial Height Class II Division 2 Class II Skeletal an open bite malocclusion). Malocclusion Abnormal lower facial height can be evaluated by ...... relating the upper facial height [Eyebrows to the E. Skeletal Deep Bite base of the nose] to the lower facial height [base Class III Malocclusion Class III Skeletal Evaluating the vertical proportions of the face of the nose to the bottom of the chin] (Figure 6). can also guide the practitioner to recognize ...... The proportionality of the upper facial height to abnormally decreased lower facial height lower facial height is ideally 50:50. A skeletal problem is defined as an anatomical that is often associated with a hypodivergent condition that contributes to malocclusion or D. Skeletal Open Bite growth pattern. In this condition, the mandible facial deformity. The diagnostic “gold standard,” Evaluating the vertical proportions of the face rotates upward and forward during growth. is whether the condition is clinically significant guides the practitioner to recognize abnormal Severe clinical expressions of hypordivergence and treatment would be recommended. vertical skeletal growth patterns. Excessive will present as a skeletal deep bite (the skeletal

Figure 4 - Facial Landmarks for Profile Figure 5 - Facial Analysis in Frontal View: Figure 6 - Facial Analysis in Frontal View: View Midlines and Symmetry Vertical Proportions

Facial Profile Landmarks: 1. Most prominent point on forehead 2. Base of nose Facial Midline Facial Thirds 3. Most prominent point of chin

www.metdental.com Page 4 Quality Resource Guide – Management of Malocclusion and Skeletal Problems 3rd Edition relationship is a contributing factor for the deep B. Oral Habits After developing the problem list, the next task is bite). The diagnosis of this condition should be Thumb sucking: Maxillary dento-alveolar to address each problem listed, with a treatment confirmed by cephalometric analysis. protrusion (proclined or protruded maxillary objective. Treatment objectives should direct the anterior teeth), maxillary constriction. practitioner to a goal of therapy. Again, the diagnostic “gold standard” depends on clinical significance or is this worth treating? If Lip sucking/biting: Maxillary dento-alveolar Examples of treatment objectives matched to the hypodivergence adversely affects facial esthetics protrusion (proclined or protruded maxillary problem list. anterior teeth), mandibular dento-alveolar (deficient lower facial height) or contributes to a Problem List Treatment Objective retrusion (retroclined mandibular anterior teeth). deep bite malocclusion, it is critical to recognize ...... this condition. C. Abnormal Swallow Class II Division 1 Establish a normal Tongue thrusting: Bimaxillary dento-alveolar Malocclusion Class 1 Occlusion 5. Functional Conditions protrusion (proclined or protruded maxillary and ...... Recognizing abnormal tooth position can many mandibular anterior teeth). Overbite = 100% Reduce the overbite times lead to a better understanding of the Overjet = 6 mm and overjet etiology of the condition. If certain functional D. Abnormal Breathing problems are not recognized and addressed, an Mouth breathing: maxillary constriction...... unstable orthodontic correction may result. The Severe maxillary Eliminate maxillary E. Bruxism/Clenching following conditions may lead to specific changes anterior spaces spaces Although not clearly associated with abnormal in tooth position. The effect on tooth position will tooth position, these conditions may be associated ...... vary depending on the frequency, duration, and with incisal/occlusal wear and attrition. Maxillary dental midline Center the maxillary force applied. Normally, teeth are not in occlusion. Maximum midline deviated to the dental midline to the A. Labial Incompetence intercuspation and lateral excursions are mostly right side facial midline Normally lips meet without muscle strain. Some diagnostic reference positions used by dentists to ...... patients present with lips separated at rest more guide rehabilitation. During bruxism and clenching, Skeletal Class II Establish a normal than 3-4 mm. When instructed to bring the lips patients function abnormally in occluded positions. Mandibular retrusion Class 1 skeletal together, the patient may demonstrate mentalis Consequently, the accommodative capability of Relationship muscle strain (Figure 7). Labial incompetence oral structures may be exceeded...... may be associated with excessively protruded 6. Problem List and Treatment incisors as well as with other skeletal conditions Objectives 7. Treatment Planning including increased lower facial height. The problem list commits significant findings After recognizing a condition that would benefit to the dental record, focusing on the problems from orthodontic treatment, the dentist should Figure 7 - Labial Incompetence to be managed by the dentist. It includes the develop a treatment plan that is within his/her patient’s treatment needs and desires. It should therapy skill set. A treatment plan should be a include conditions that relate to: Pain, Pathology, sequential list of dental and non-dental services Dysfunction, and Concerns of the patient required to address the patient’s problems. The (including esthetics). order of the list should be rational, addressing For the management of malocclusion and skeletal the patient’s concerns, oral/dental disease, and problems, the problem list should include: dysfunction. Since clinical orthodontic treatment is often not emphasized in many predoctoral 1. Angle Classification dental education programs, many general 2. Overbite/Overjet dentists may choose to use the services of 3. Spacing/Crowding orthodontists to manage his/her patients. 4. Midline position 5. Abnormal tooth positions Before initiating orthodontic treatment, the 6. Other significant findings: Skeletal Problems, dentist should be certain that the patient is free Habits, Functional problems, Disturbances of of etiologic factors and/or conditions causing normal dental development, etc. pain, pathology, and dysfunction. A sequential www.metdental.com Page 5 Quality Resource Guide – Management of Malocclusion and Skeletal Problems 3rd Edition treatment plan should begin with obtainment 8. One Caveat: Smile Esthetics in the smile zone. Possible reasons for this may of medical, dental, and periodontal clearance. Esthetic perceptions frequently drive treatment include: dental crowding with inadequate formation The most important role for the general dentist planning. Even subtle irregularities of anterior of papilla in gingival embrasure, triangular shaped is to determine the spectrum of services [e.g. teeth may be of concern to the patient. The dentist teeth, periodontal disease, and mesial angulation of , implants, esthetic dentistry, oral should listen carefully to the patient and develop teeth. Finally consider the soft tissue frame for the surgery, orthodontics, etc.] needed to adequately a systematic approach when evaluating the smile. smile (Figure 8). The upper boundary is the upper address the patient’s condition, and to coordinate This process begins by looking at individual teeth lip or lip line. Although, severe, “gumminess” may the delivery of interdisciplinary care. considering: color, contour/ shape, and proportion indicate a skeletal condition, “vertical maxillary (length, width). After that, consider the alignment excess,” even a moderately high lip line may be The patient evaluation form (Attachment 1) of the teeth in all planes: angulations, inclinations, of concern if gingival margin heights are uneven/ incorporates the concepts described in this article rotations, and vertical positions. Examine the asymmetrical (Figure 9). The lower boundary of (Table 1). It should assist the dentist to collect maxillary dental midline relative to the facial the smile is the lower lip, and is referred to as the clinical information during dental examinations, midline. Next consider soft tissue factors that affect smile line or arc (Figure 10). Laterally the smile is thus facilitating the integration of the diagnostic the smile. This begins with inspection of gingival framed by the, “buccal corridor.” Generally teeth and treatment planning concepts discussed in margins, contours, and interproximal papilla. A should fill the soft tissue frame for an esthetically this guide. punched out papilla or black triangle is of concern pleasing smile.

Figure 9 Figure 10 Figure 11

Upper Lip - Lip Line

Buccal Teeth Buccal Corridor Corridor

Lower Lip - Smile Line (arc) High Lip Line. Notice the gingival margins Smile line or arc. Notice the relationship of the maxillary incisors and several mm between the incisal edges of the maxillary Soft tissue frame of the smile. beyond. Even if the gingival display is within anterior teeth and the lower lip. acceptable limits, the symmetry of gingival margins may be of concern.

The author gratefully acknowledges Robin David Lipp for his assistance preparing the illustrations used in this guide.

REFERENCES

1. Arnett GW, Bergman RT. Facial keys to orthodontic diagnosis and treatment planning. Part I. Am J Orthod Dentofacial Orthop 1993:103: 299-312. 2. Arnett GW, Bergman RT. Facial keys to orthodontic diagnosis and treatment planning. Part II. Am J Orthod Dentofacial Orthop 1993:103: 395-411. 3. Calamia J, Levine JB, Lipp M, Cisneros G, Wolff M, “Smile Design and Treatment Planning With the Help of a Comprehensive Esthetic Evaluation Form,” in Esthetic and Cosmetic Dentistry for Modern Dental Practice: Update 2011, Dental Clinics of North America, 2011:55 (2): 187-209. 4. Lipp MJ, “A Guide Toward Clinical Competence: Management of Malocclusion and Skeletal Problems for the Dentist” Chapters 24, Essentials for Orthodontic Practice EFOP Press 3rd edition , 2015 Editors: Riolo ML, Cangialosi TJ, Hartsfield JK, Lipp MJ, Grubb JE, Watkins T 5. Lipp, MJ, “An Objectified” Competency-Based Course in the Management of Malocclusion and Skeletal Problems. J Dent Educ 2008:72 (5): 545- 554. 6. Proffit WR. Contemporary Orthodontics. Fourth edition. St. Louis: Mosby/Elsevier, 2006.

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Figure 8 - Orthodontic Diagnosis and Treatment Planning: Patient Evluation Form

Patient Name (last, first)______Date______Concern(s)______

Face Frontal View _ WNL _ Asymmetry Lips in rest _ WNL _ Together Strained [Labial incompetence] Lower Facial Height [Sn-Me’] _ WNL _ Excess _ Deficient Max Vertical Height (smile) _ WNL _ Vertical Maxillary Excess Face Profile View __ WNL Skeletal Class II _ Skeletal Class III

Abnormal Function(s): _ Digit sucking [e.g., Thumb] _ Lip sucking/biting _ Object sucking/biting _ Mouth breathing _ Tongue Thrust Swallow _ Clenching _ Grinding/Bruxism _ Other

Intra-Oral Analysis: Midline _ WNL [Upper and lower dental midlines coincide with the facial midline] _ Upper dental deviated to the R _ L _ _ Lower dental deviated to the R _ L __ Dental Shift _ Functional shift Overbite _ Negative [open bite] _ WNL [0-30%] _ Moderate _ Severe [almost 100%] Overjet _ Negative [crossbite] _ WNL [1-2mm] _ Moderate [3-5mm] _ Severe [5+ mm] Max _ WNL _ Crowding _ Spacing _ Mild [0-2mm] _ Moderate [3-5mm] _ Severe [5+ mm] Mand _ WNL _ Crowding _ Spacing _ Mild [0-2mm] _ Moderate [3-5mm] _ Severe [5+ mm] _ Anterior Crossbite _ Dental _ Skeletal [Class III] _ Functional Shift _ Posterior Crossbite R _ L __ Dental _ Functional shift

_ Abnormal tooth position(s) ______

Classification of Occlusion/Malocclusion: _ Normal _ Class I Mal _ Class II Div 1 Mal _ Class II Div 2 Mal _ Class III Mal

Summary of Problems [Check ALL that apply] Condition WNL/Mild Moderate Severe Not applicable Overbite Overjet Max-Spacing/Crowding Mand- Spacing/Crowding YES NO Open bite Functional shift

Treatment Advice [Check ONE only]: _ Comprehensive Orthodontic Treatment [COT] _ COT in conjunction with Growth modification for Skeletal Class II/Skeletal Class III _ COT in conjunction with Orthognathic Surgery _ Limited Orthodontic Treatment [1 arch or segmental treatment]: Estimated treatment time______months _ No Treatment, Recall Patient in ______month

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Clinical Case Simulation Figures 12-17 for Post Test

Figure 12 - Facial Photographs Figure 15 - Occlusal Views

Figure 13 - Intra-Oral Anterior View in MIP

Figure 16 - Panoramic Radiograph

Figure 14 - Intra-Oral Side Views in MIP

Figure 17 - Cephalometric Panoramic Radiograph

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POST-TEST Internet Users: This page is intended to assist you in fast and accurate testing when completing the “Online Exam.” We suggest reviewing the questions and then circling your answers on this page prior to completing the online exam. (1.0 CE Credit Contact Hour) Please circle the correct answer. 70% equals passing grade.

The following multiple-choice questions are based on the Clinical Case Simulation Figures 12-17 on the previous page. This is a 29-year-old patient.

1. Dental crowding in the maxillary arch is: 6. The best explanation of the midline discrepancy is: a. Moderate: 3-4mm generalized in the arch a. Maxillary dental midline is deviated to the right side b. Moderate: 3-4 mm localized in the anterior region b. Mandibular dental midline is deviated to the left side c. Severe 5+ mm generalized in the arch c. Mandibular functional shift to the left side d. Severe: 5+ mm localized in the anterior region d. Cannot be determined e. None of the above e. None of the above

2. Dental crowding in the mandibular arch is: 7. Position of maxillary anterior teeth: a. Moderate: 3-4mm generalized in the arch a. Within normal limits b. Moderate: 3-4 mm localized in the posterior region b. Abnormal: Open bite c. Severe 5+ mm generalized in the arch c. Abnormal: Proclined d. Severe: 5+ mm localized in the posterior region d. Abnormal: Functional shift e. None of the above e. None of the above

3. Overbite: 8. Treatment: a. Mild: 5-30% a. Comprehensive Orthodontics b. Moderate: 30-70% b. Orthognathic surgery c. Severe: Approaching 100% c. Comprehensive Orthodontics in conjunction with orthognathic d. Cannot be determined surgery e. None of the above d. Esthetic Dentistry e. More than one of the above depending on the objectives of 4. Molar Occlusion: treatment a. Class I b. Class II 9. Position of mandibular anterior teeth: c. Class III a. Within normal limits d. Cannot be determined b. Abnormal: Open bite e. None of the above c. Abnormal: Proclined d. Abnormal: Retroclined 5. Canine Occlusion: e. None of the above a. Class I b. Class II 10. Which statement is correct? c. Class III a. # 4 is lingual and in crossbite d. Cannot be determined b. #7 is lingual and in crossbite e. None of the above c. #20 is lingual and in crossbite d. #29 is lingual and in crossbite e. Cannot be determined

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Name (Last, First, Middle Initial):______PLEASE PRINT CLEARLY Street Address:______Suite/Apt. Number______

City: ______State:______Zip:______

Telephone: ______Fax:______FOR Date of Birth:______Email: ______OFFICE State(s) of Licensure:______License Number(s):______USE ONLY Preferred Dentist Program ID Number:______Check Box If Not A PDP Member

AGD Mastership: Yes No

AGD Fellowship: Yes No Date:______

Please Check One: General Practitioner Specialist Dental Hygienist Other

Quality Resource Guide – Management of Malocclusion and Skeletal Problems 3rd Edition

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