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4 5 Clinical Practice Guidelines 6 for 7 and 8 Dentofacial Orthopedics 2008 9 10 11 12 13 14 15 This document may not be copied or reproduced without the 16 express written permission of the AAO 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 © 2008 2012 American Association of Orthodontists 34 Created: 1996 35 Amended: 2001, 2009, 2010, 2012, 2014 36 Date: September 9, 2008; Adopted May 2009 37 Amended May 2010 38 Amended May 2012 39 1

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1 TABLE OF CONTENTS 2 3 Clinical Practice Guidelines for Orthodontics and 1 4 Dentofacial Orthopedics 2008 1 5 This document may not be copied or reproduced without the 1 6 express written permission of the AAO 1 7 Introduction…………………………………………………………………………………………………. 3 8 Pretreatment Considerations…………………………………………………………………………... 4 9 Examination………………………………………………………………………………………………… 4 10 Diagnostic Records……………………………………………………………………….………………. 5 11 Referral……………………………………………………………………………………………………... 5 12 Diagnosis and Treatment………………………………………………………………………………... 5 13 Anomalies of Jaw Size, Relationship of Jaw to Cranial Base, Dental Arch Relationship and Dental 14 Alveolus…………………………………………………………………………………………………….. 6 15 Anomalies of Tooth Position, Discrepancies of Tooth Size and Arch Length………………………. 9 16 Abnormalities of Tooth Number Morphology, and Eruption Pattern………………………………….10 17 Dentofacial Functional Abnormalities……………………………………………………………………12 18 Craniofacial Anomalies, Cleft Lip and Palate…………………………………………………………...13 19 Treatment Objectives and Limiting Factors……………………………………………………………..14 20 Goals………………………………………………………………………………………………………...14 21 Limiting Factors…………………………………………………………………………………………….14 22 Treatment Consultation and Informed Consent………………………………………………………...14 23 Risks Associated with Orthodontic Treatment………………………………………………………….15 24 Risks Associated with Adjunctive Procedures in Orthodontics……………………………………….16 25 Post Treatment Evaluation and Outcomes Assessment………………………………………………16 26 Post Treatment Records…………………………………………………………………………………..16 27 Positive Outcomes of Treatment…………………………………………………………………………16 28 Negative Outcomes of Treatment………………………………………………………………………..17 29 Retention……………………………………………………………………………………………………17 30 Record Keeping…………………………………………………………………………………………….17 31 Transfer of Orthodontic Patients………………………………………………………………………….18 32 Recommendations to the Transferring Practitioner…………………………………………………….18 33 Recommendations to the Accepting Practitioner……………………………………………………….18 34 Patients Who Wish to Transfer because of Dissatisfaction with Current Orthodontist……………..19 35 Recommendations to the Transferring Practitioner…………………………………………………..19 36 Recommended Procedures for Accepting Orthodontist……………………………………………...19 37 Evidence-Based ………………………………………………………………………………...19 38 Definition…………………………………………………………………………………………………….19 39 Levels of Evidence…………………………………………………………………………………………20 40 Best Evidence………………………………………………………………………………………………20 41 Evidence-Based Clinical Recommendations……………………………………………………………20 42 HIPAA……………………………………………………………………………………………………….20 43 Appendix A: Historical Development ……………………………………………………..…………….22 44 Appendix B: Updating of Clinical Practice Guidelines…………………………………………………23 45 Appendix C: Clinical Practice Guidelines Members………………….………………………………..25 46 Selected References………………………………………………………………………………………25 47

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1 Introduction 2 3 Orthodontics and Dentofacial Orthopedics is a the specialty area of dentistry concerned with the 4 supervision, guidance and correction of the growing or mature dentofacial structures, including 5 those conditions that require movement of teeth or correction of malrelationships and 6 malformations of their related structures and the adjustment of relationships between and among 7 teeth and facial bones by the application of forces and/or the stimulation and redirection of 8 functional forces within the craniofacial complex. Major responsibilities of orthodontic practice 9 include the diagnosis, prevention, interception, and treatment of all forms of of the 10 teeth and associated alterations of their surrounding structures; the design, application, and 11 control of functional and corrective appliances; and the guidance of the dentition and its supporting 12 structures to attain and maintain optimal occlusal relations and physiologic and esthetic harmony 13 among facial and cranial structures. 14 15 A specialist in orthodontics and dentofacial orthopedics meets educational standards established 16 by the Commission on Dental Accreditation of the American Dental Association (ADA) and must 17 possess advanced knowledge in biomedical, clinical, and basic sciences. This knowledge includes 18 the biology of tooth movement, cephalometrics, orthodontic diagnosis, treatment planning, surgical 19 orthodontics, biomechanical principles, the effects of growth and development on tooth movement, 20 application of orthopedic forces to dentofacial structures, and patient management and motivation. 21 22 The American Association of Orthodontists (AAO) is the leading national organization of dentists 23 who limit their practice to orthodontics and dentofacial orthopedics and is recognized by the ADA 24 as the sponsoring organization of the national certifying board, the American Board of 25 Orthodontics. The membership of the AAO includes approximately 94% of practicing orthodontists 26 in the United States. The AAO has the background, expertise, and professional responsibility to 27 assist the dental profession and the public by developing clinical practice guidelines for 28 orthodontics and dentofacial orthopedics. The AAO recognizes its role in upholding the public trust 29 granted to it by presenting these clinical practice guidelines to help practitioners develop 30 judgments on diagnosis, treatment planning, and timing of orthodontic and dentofacial orthopedic 31 therapy. The primary concern of the AAO is the provision of high quality orthodontic care and the 32 protection of the public. 33 34 Practice guidelines, as defined by the Institute of Medicine, are “systematically developed 35 statements to assist practitioner and patient decisions about appropriate health care for specific 36 clinical circumstances.” 37 38 The Orthodontic Clinical Practice Guidelines for Orthodontics and Dentofacial Orthopedics 39 presented in this document are condition based and are related to the International Classification 40 of Diseases, Clinical Modification, 9th Edition (ICD-9Codes). This approach recognizes the need 41 for integrated treatment of oral and dentofacial conditions rather than isolated treatment 42 procedures. These guidelines are also directed toward the process of patient care and outline 43 considerations related to diagnosis, treatment, and quality of care. 44 45 These guidelines were derived from a professional consensus, based on a review of relevant 46 clinical and scientific literature, the expert opinion of educators, and the clinical experience of 47 practicing orthodontists. Similar documents written by other organizations and publications related 48 to guideline development were also reviewed. 49 50 There are various professionally accepted philosophies regarding orthodontic diagnosis, 51 treatment, and retention. Because of the nature of the doctor-patient relationship, the practitioner,

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1 who is actively engaged in treating the patient, is in the best position to evaluate and interpret the 2 complexities, timing, and potential efficacy from among different the many treatment philosophies 3 and systems available. Deviations from these guidelines may be appropriate based on 4 professional judgment and individual patient needs. Where a practitioner chooses to deviate from 5 these guidelines (based on the circumstances of a particular patient or for any other reason) the 6 practitioner is advised to note in the patient's record the reason for the procedure followed. Finally, 7 it should be understood that adherence to these guidelines does not guarantee a successful 8 treatment outcome. 9 10 The AAO recognizes that these guidelines may be used by insurance carriers and other payers, 11 attorneys in malpractice litigation, and various entities with an interest in orthodontics. The 12 Association encourages all interested persons to become familiar with the Guidelines. This 13 document was not developed to establish standards of care or to be used for reimbursement or 14 litigation purposes. The AAO cautions that these uses involve considerations that are beyond the 15 scope of the Guidelines. 16 17 The professional conduct of members of the AAO is governed by the Principles of Ethics and 18 Code of Professional Conduct of the AAO and the ADA. 19 20 Pretreatment Considerations 21 22 A screening examination may be performed to determine the nature of the orthodontic problem, 23 and to determine if and when treatment is indicated. When treatment is indicated, a 24 comprehensive examination must be performed that should include: 25 26 Examination 27 28 A. Chief Complaint 29 The chief complaint or the reason for seeking treatment should be recorded as described 30 by the patient, parent or legal guardian. 31 B. Medical and Dental History 32 An appropriate medical and dental history must be obtained as a part of the initial 33 evaluation of the patient. If treatment is to be delayed until a future date, an updated history 34 may be necessary. Patients/parents/legal guardians should be requested to advise the 35 orthodontist of any change in the patient's health history. 36 37 C. Clinical Examination 38 A comprehensive clinical examination should include the following with all findings 39 recorded in the patient's record: 40 41 1. An extraoral facial assessment to determine facial form, symmetry, soft-tissue 42 harmony, and status of the perioral musculature. This determines deviations from 43 normal regarding a patient's sagittal, vertical, and transverse maxillofacial 44 relationships and to assess the relationship of the dentition to the facial structures. 45 2. An intraoral examination to assess the condition of the hard and soft tissues of the 46 mouth, (including the periodontium) and the static and functional status of the 47 patient's . 48 3. An evaluation of the temporomandibular joint and associated musculature to 49 assess function and disease. 50

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1 Diagnostic Records 2 3 Diagnostic records and tests will vary with the nature of the patient's condition but must be 4 sufficient to identify the problems, formulate a diagnosis, and allow the development of an 5 acceptable course of treatment. Where limited orthodontic procedures are anticipated, diagnostic 6 records may vary from those associated with comprehensive care. Pretreatment unaltered 7 diagnostic records for comprehensive orthodontic treatment should include the following to 8 establish a baseline for documenting treatment and/or growth changes: 9 10 1. Extra and intraoral images (may include digital or video images) to supplement the 11 clinical findings. 12 2. Dental casts (or digital models) to assess the inter-arch and intra-arch relationship 13 of the teeth, to help determine arch length and width requirements, and to assess 14 arch symmetry. 15 3. Intraoral and/or panoramic radiographs to assess the condition and developmental 16 status of the teeth and associated structures, and to identify any dental anomalies 17 or pathology. 18 4. Cephalometric radiographs to permit evaluation of the size, shape, and positions of 19 the craniofacial structures and dentition, and to aid in the identification of skeletal 20 anomalies or pathology. Three-dimensional cone-beam computer tomography 21 (CBCT) may be used as an alternate (imaging) source to obtain dentofacial 22 information. 23 5. The AAO recognizes that while there may be clinical situations where a cone-beam 24 computed tomography (CBCT) radiograph may be of value, the use of such 25 technology is not routinely required for orthodontic radiography. 26 27 Referral 28 29 Practitioners must make a recommendation for referral of patients to general dentists, other dental 30 specialists, physicians, or other health care practitioners whenever, in the judgment of a 31 practitioner, referral would be in the best interest of a patient. Technological advances such as 32 CBCT scans fall in this category and should be assessed/read in their entirety by a qualified 33 professional; the entire area encompassed by the scan may be the responsibility of the 34 practitioner. 35 36 Diagnosis and Treatment 37 38 Prior to the initiation of orthodontic treatment, a diagnosis of the patient's oral health condition 39 must be made. A diagnosis allows for the development of a treatment plan that addresses the 40 patient's chief complaint; medical and dental history; and dental, facial, skeletal, functional, and/or 41 psychosocial problems. 42 43 After a diagnosis has been established, a treatment plan must be developed. Such a plan will 44 facilitate coordination of the treatment objectives and the various methods available for addressing 45 them. The plan should include: 46 47 1. A list of the patient's dental, facial, skeletal, functional, and/or psychosocial 48 problems. 49 2. A differential diagnosis which coordinates the patient/parents/legal guardian's chief 50 complaint with the clinical findings.

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1 3. A written documented plan for therapy which includes treatment goals, appliance 2 selection, sequencing and timing of treatment, coordination with other health care 3 providers, and retention. 4 5 The treatment plan should be periodically reassessed throughout treatment. This reassessment 6 should take into consideration various limiting factors and establish short- and/or long-term 7 objectives. 8 9 Anomalies of Jaw Size, Relationship of Jaw to Cranial Base, Dental Arch Relationship and 10 Dental Alveolus 11 12 The following conditions may indicate the need for orthodontic or dentofacial orthopedic treatment. 13 These conditions may be structural or functional, may appear in various combinations, and are not 14 limited to the following. Frequently used treatment options, which may include the removal of 15 primary or permanent teeth, are listed for each condition. Moreover, devices including headgear, 16 osseointegrated implants, mini-screw implants, miniplates and other temporary devices 17 may be used as adjuncts to improve facilitate the treatment outcome, in particular where maximum 18 anchorage would be beneficial. 19 20 I. Maxillary/Dentoalveolar Hyperplasia (Large Maxilla) 21 22 A. Diagnostic Considerations 23 24 1. Anteroposterior 25 a. Excess Overjet 26 b. Distoclusion 27 c. Asymmetry 28 d. Mid-Face Protrusion 29 2. Vertical 30 a. Long Face Height 31 b. Deep 32 c. Open Bite 33 d. Lip Incompetency 34 e. Asymmetry 35 3. Transverse 36 a. Buccal Maxillary Cross-bite (unilateral or bilateral; functional or 37 structural) 38 b. Asymmetry 39 40 B. Treatment Options 41 42 1. Primary Dentition - Treatment Indicated Under Certain Circumstances, 43 Appliances Vary 44 2. Mixed Dentition 45 a. Functional/Orthopedic Appliances 46 b. Fixed or Removable Orthodontic Appliances 47 3. Adolescent Dentition 48 a. Functional/Orthopedic Appliances 49 b. Fixed or Removable Orthodontic Appliances 50 c. Fixed Orthodontic Appliances Adjunctive to Orthognathic Surgery 51 (surgery usually performed after majority of growth completed)

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1 4. Adult Dentition 2 a. Fixed or Removable Orthodontic Appliances 3 b. Fixed Orthodontic Appliances Adjunctive to Orthognathic Surgery 4 5 II. Maxillary/Dentoalveolar Hypoplasia (Small Maxilla) 6 7 A. Diagnostic Considerations 8 9 1. Anteroposterior 10 a. Mesiocclusion 11 b. Anterior Cross-bite (functional or structural) 12 c. Asymmetry 13 d. Mid-Face Deficiency 14 2. Vertical 15 a. Short Face Height 16 b. Deep Overbite 17 c. Open Bite 18 d. Lip Redundancy 19 e. Asymmetry 20 3. Transverse 21 a. Lingual Posterior Cross-bite (unilateral or bilateral; functional or 22 structural) 23 b. Asymmetry 24 25 B. Treatment Options 26 27 1. Primary Dentition 28 a. Functional/Orthopedic Appliance 29 b. Fixed or Removable Orthodontic Appliance 30 2. Mixed Dentition 31 a. Functional/Orthopedic Appliance 32 b. Fixed or Removable Orthodontic Appliance 33 3. Adolescent Dentition 34 a. Functional/Orthopedic Appliance 35 b. Fixed or Removable Orthodontic Appliance 36 4. Adult Dentition 37 a. Fixed or Removable Orthodontic Appliance 38 b. Fixed Orthodontic Appliance Adjunctive to Orthognathic Surgery 39 40 III. Mandibular/Dentoalveolar Hyperplasia (Large Mandible) 41 42 A. Diagnostic Considerations 43 44 1. Anteroposterior 45 a. Prognathic Facial Pattern 46 b. Mesiocclusion 47 c. Anterior Cross bite (functional or structural) 48 d. Macrogenia 49 e. Asymmetry 50 2. Vertical 51 a. Open Bite

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1 b. Deep Overbite 2 c. Long Lower Facial Height 3 d. Asymmetry 4 3. Transverse 5 a. Posterior Cross-bite (unilateral or bilateral; functional or structural) 6 b. Asymmetry 7 8 B. Treatment Options 9 10 1. Primary Dentition - Treatment Indicated Under Certain Circumstances, 11 Appliances Vary 12 2. Mixed Dentition 13 a. Functional/Orthopedic Appliance 14 b. Fixed or Removable Orthodontic Appliance 15 3. Adolescent Dentition 16 a. Functional/Orthopedic Appliance 17 b. Fixed or Removable Orthodontic Appliance 18 4. Adult Dentition 19 a. Fixed or Removable Orthodontic Appliance 20 b. Fixed Orthodontic Appliance Adjunctive to Orthognathic Surgery 21 22 IV. Mandibular/Dentoalveolar Hypoplasia (Small Mandible) 23 24 A. Diagnostic Considerations 25 26 1. Anteroposterior 27 a. Mandibular Retrognathic Facial Pattern 28 b. Excess Overjet 29 c. Distoclusion 30 d. Asymmetry 31 2. Vertical 32 a. Open Bite 33 b. Deep Overbite 34 c. Short Lower Face Height 35 d. Long Lower Face Height 36 3. Transverse 37 a. Posterior Cross-bite (unilateral or bilateral; functional or structural) 38 b. Asymmetry 39 40 B. Treatment Options 41 42 1. Primary Dentition - Functional/Orthopedic Appliance 43 2. Mixed Dentition 44 a. Functional/Orthopedic Appliance 45 b. Fixed or Removable Orthodontic Appliance 46 3. Adolescent Dentition 47 a. Functional/Orthopedic Appliance 48 b. Fixed or Removable Orthodontic Appliance 49 c. Appliance Adjunctive to Orthognathic Surgery (surgery usually 50 performed after majority of growth completed) 51 4. Adult Dentition

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1 a. Fixed or Removable Orthodontic Appliance 2 b. Fixed Orthodontic Appliance Adjunctive to Orthognathic Surgery 3 4 Anomalies of Tooth Position, Discrepancies of Tooth Size and Arch Length 5 6 These conditions may appear in various combinations and are not limited to the following. 7 Frequently used treatment options for these anomalies may include modification of tooth size, 8 surgical exposure, extraction of primary or permanent teeth, and appropriate soft tissue surgery. 9 10 I. Deficient Arch Length (Crowding) 11 12 A. Diagnostic Considerations 13 14 1. Facial-Lingual Displacement 15 2. Supra/Infra Eruption 16 3. Rotations 17 4. Impactions 18 5. Axial Inclination of Teeth (Anterior or Posterior) 19 6. Tooth Size 20 7. Premature Loss of Primary Teeth 21 8. Ankylosis 22 23 B. Treatment Options 24 25 1. Primary Dentition 26 Fixed or Removable Space Maintainer 27 2. Mixed Dentition 28 a. Functional/Orthopedic Appliance 29 b. Fixed or Removable Orthodontic Appliance 30 c. 31 3. Adolescent Dentition 32 a. Fixed or Removable Orthodontic Appliance 33 b. Functional/Orthopedic Appliance 34 4. Adult Dentition 35 Fixed or Removable Orthodontic Appliance 36 37 II. Excessive Arch Length (Spacing) 38 39 A. Diagnostic Considerations 40 41 1. Facial-Lingual Displacement 42 2. Axial Inclination of Teeth 43 3. Fibrous Gingival Hyperplasia 44 4. Frena 45 5. Tooth Size 46 47 B. Treatment Options 48 49 1. Primary Dentition - Treatment Rarely Indicated 50 2. Mixed Dentition - Fixed or Removable Orthodontic Appliance 51 3. Adolescent Dentition - Fixed or Removable Orthodontic Appliance

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1 4. Adult Dentition - Fixed or Removable Orthodontic Appliance 2 3 III. Discrepancies of Arch Form 4 5 A. Diagnostic Considerations 6 7 1. Asymmetry 8 2. Interarch Coordination 9 3. Abnormal Occlusal Planes: Curves of Wilson and Spee 10 11 B. Treatment Options 12 13 1. Primary Dentition - Fixed or Removable Orthodontic Appliance 14 2. Mixed Dentition 15 a. Fixed or Removable Orthodontic Appliance 16 b. Functional/Orthopedic Appliance 17 3. Adolescent Dentition 18 a. Fixed or Removable Orthodontic Appliance 19 b. Functional/Orthopedic Appliance 20 4. Adult Dentition 21 a. Fixed or Removable Orthodontic Appliance 22 b. Fixed Orthodontic Appliance Adjunctive to Orthognathic Surgery 23 24 Abnormalities of Tooth Number Morphology, and Eruption Pattern 25 26 Anomalies of tooth number, morphology or eruption pattern should be diagnosed and managed as 27 soon as reasonably practical according to the particular requirements of each clinical situation. 28 These conditions may appear in various combinations, and may indicate the need for orthodontic 29 or dentofacial orthopedic treatment. Some of the frequently used treatment options may require a 30 multidisciplinary approach and may include the extraction of primary or permanent teeth. 31 32 A. Diagnostic Considerations 33 34 1. Supernumerary Teeth 35 2. Missing Teeth 36 a. Congenital (Anodontia) 37 b. Pathologic 38 c. Traumatic 39 d. Extracted 40 3. Ectopic Erupting Teeth 41 4. Impacted Teeth 42 5. Eruption Anomalies 43 6. Over-Retained Primary Teeth 44 7. Ankylosed Teeth 45 8. Transposition 46 9. Atypical Crown Morphology 47 10. Premature Loss of Primary Teeth 48 11. Atypical Root Morphology 49 12. Root Resorption 50 13. Carious or Fractured Teeth 51

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1 B. Treatment Options 2 3 1. Supernumerary Teeth 4 a. Surgical Intervention 5 b. Extraction 6 c. Fixed or Removable Orthodontic Appliance 7 2. Missing Teeth 8 a. Space Maintenance 9 b. Fixed or Removable Orthodontic Appliance 10 c. Prosthetic Replacement of Teeth/Implants 11 d. Transplantation 12 e. Maintenance of Primary Teeth 13 f. Space Closure 14 3. Ectopic Teeth 15 a. Fixed or Removable Orthodontic Appliance 16 b. Extraction 17 4. Impacted Teeth 18 a. Surgical Intervention 19 b. Extraction 20 c. Fixed or Removable Orthodontic Appliance 21 5. Eruption Anomalies 22 a. Surgical Intervention 23 b. Retention with or without Coronal Modification 24 c. Extraction 25 d. Fixed or Removable Orthodontic Appliance 26 e. Referral for Medical Evaluation 27 6. Over-Retained Primary Teeth Extraction 28 a. Extraction 29 7. Ankylosed Teeth 30 a. Extraction 31 b. Surgical Luxation 32 c. Surgical Repositioning 33 d. Fixed or Removable Orthodontic Appliance 34 e. Retention with or without Coronal Modification 35 8. Transposition 36 a. Fixed or Removable Orthodontic Appliance 37 b. Extraction 38 c. Retention with or without Coronal Modification 39 d. Transplantation 40 9. Atypical Tooth Morphology 41 a. Retention with or without Coronal Modification 42 b. Extraction 43 c. Fixed or Removable Orthodontic Appliance 44 10. Premature Loss of Primary Teeth 45 a. Space Maintenance 46 b. Fixed or Removable Orthodontic Appliance 47 11. Atypical Root Morphology 48 a. Monitor Radiographically 49 b. Extraction 50 12. Root Resorption 51 a. Monitor Radiographically

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1 b. Extraction 2 c. Stabilization 3 13. Carious or Fractured Teeth 4 a. Reposition Tooth or Root 5 b. Fixed or Removable Orthodontic Appliance 6 7 Dentofacial Functional Abnormalities 8 9 55 Dentofacial functional abnormalities may occur in combination with other dentofacial conditions 10 and should be diagnosed and managed according to the particular requirements of each clinical 11 situation. Correction or control of functional problems may involve alteration of behavior patterns, 12 may require orthodontic/dentofacial orthopedic treatment, or multidisciplinary treatment. The 13 influence of functional abnormalities on dentofacial development is variable, and cause and effect 14 relationships are difficult to determine. 15 16 A. Diagnostic Considerations 17 18 1. Lip Size and Function 19 2. Tongue Size and Function 20 a. Abnormal Tongue Function 21 b. Ankyloglossia 22 c. Microglossia or Macroglossia 23 3. Deleterious Habits 24 a. Thumb, Finger or Lip Sucking 25 b. Pacifier Sucking 26 c. Tongue Thrust/Sucking 27 d. Clenching 28 e. Grinding 29 f. Lip/Cheek Biting 30 g. Nail Biting 31 h. Foreign Objects (e.g., pipes, pens, pencils, musical instruments) 32 4. Airway Obstruction 33 a. Nasopharyngeal Morphology 34 b. Sleep Apnea 35 c. Allergies 36 d. Pathology 37 5. Speech Disorders 38 6. Mandibular Dysfunction 39 a. Dental Interferences 40 b. Skeletal Abnormalities 41 c. Neuromuscular Abnormalities 42 d. Temporomandibular Dysfunction 43 7. Temporomandibular Disorders 44 Temporomandibular disorders represent a broad range of conditions which involve 45 medical, dental, and psychological factors. Such disorders may be associated with 46 stress, habits, emotional disorders, structural malrelationships, trauma to the face 47 or head, occlusal disharmonies, and medical problems associated with 48 osteoarthritis, rheumatoid arthritis, or viral disease. These factors may be 49 associated with temporomandibular disorders in one individual with no 50 symptomatology or pathology in another. 51

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1 B. Treatment Options 2 1. Lip Size and Function 3 a. Fixed or Removable Orthodontic Appliance 4 b. Therapeutic Exercises 5 c. Functional/Orthopedic Appliance 6 d. Surgery 7 2. Tongue Size and Function 8 a. Fixed or Removable Orthodontic Appliance 9 b. Therapeutic Exercises 10 c. Functional/Orthopedic Appliance 11 d. Surgical Reduction 12 e. Lingual Frenectomy 13 3. Deleterious Habits 14 a. Fixed or Removable Orthodontic Appliance 15 b. Functional/Orthopedic Appliance 16 c. Behavior Management 17 4. Airway Obstruction 18 a. Medical Evaluation/Treatment 19 b. Functional/Orthopedic Appliance 20 c. Orthognathic Surgery 21 5. Speech Disorders 22 a. Fixed or Removable Orthodontic Appliance 23 b. Referral for Evaluation/Treatment 24 6. Mandibular Dysfunction 25 a. Occlusal Equilibration (Modification of Tooth Form) 26 b. Fixed or Removable Orthodontic Appliance 27 c. Fixed Orthodontic Appliance Adjunctive to Surgery 28 d. Functional/Orthopedic Appliance 29 7. Temporomandibular Disorders 30 Numerous treatment modalities, including orthodontics, have produced beneficial 31 results in the management of temporomandibular disorders. However, no singular 32 treatment modality may necessarily be definitive for any particular patient. There is 33 no scientific proof that any particular method of orthodontic treatment, whether 34 involving extraction or non-extraction, has any causative effect on 35 temporomandibular disorders. There is no reliable method for predicting or 36 preventing future temporomandibular disorders in any particular individual. 37 38 Craniofacial Anomalies, Cleft Lip and Palate 39 40 Management of patients with these and other anomalies is, in many cases, best provided by a 41 multidisciplinary team of dentists and physicians. The optimal time for the first evaluation of these 42 patients is within the first few days of life, and referral for team evaluation and management is 43 appropriate at any age. Treatment plans should be developed and implemented on the basis of 44 team recommendations. The orthodontist, as a member of the craniofacial defects team, should 45 evaluate those factors that may influence surgical management, assist in treatment planning, 46 obtain baseline diagnostic records and perform orthodontic treatment. 47 48 For patients at risk for developing malocclusion or maxillomandibular discrepancy, diagnostic 49 records should be collected at appropriate intervals. Depending on the goals to be accomplished, 50 periods of treatment and retention may be necessary beginning at birth. For example, patients with 51 cleft lip and cleft palate may require presurgical maxillary orthopedics to improve the position of

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1 the maxillary alveolar segments prior to lip and palate closure. Timing of bone grafting of alveolar 2 clefts should be determined by the stage of dental development and with the collaboration of the 3 orthodontist and surgeon. 4 5 Treatment Objectives and Limiting Factors 6 7 Goals 8 9 The goals of orthodontic treatment are optimum dentofacial function, health, stability and esthetics. 10 While these goals are desirable, it should be recognized that individual patients have problems, 11 concerns and conditions which may prevent the attainment of optimal results in every case, and 12 that the non-attainment of some of the goals of orthodontic treatment in a particular patient is no 13 indication of negligence by the orthodontist even when no limiting factors are present. Some 14 patients may simply wish to pursue more limited treatment goals. 15 16 Limiting Factors 17 18 Orthodontic treatment results may be affected by extenuating circumstances beyond the 19 practitioner's control. These limiting factors should be documented in the patient's record when 20 they occur and the patient/guardian should be informed. The following are some of the more 21 common limiting factors affecting orthodontic therapy: 22 23 1. Severity of the pretreatment condition 24 2. Pretreatment agreement to pursue limited objectives 25 3. Abnormal skeletal morphology or growth, during or after treatment 26 4. Abnormal size, shape, or number of teeth 27 5. Aberrant tooth eruption patterns 28 6. Patient's failure to initiate timely treatment, continue or complete treatment 29 7. Compromised periodontal tissues 30 8. Persistent deleterious habits or abnormalities of muscle function relating to the 31 dentofacial complex 32 9. Inability or unwillingness of the patient to cooperate with treatment (e.g., the wear 33 and/or care of appliances, oral hygiene measures, diet, or keeping appointments) 34 10. Failure to complete all recommended aspects of treatment 35 11. Poor quality, untimely or inappropriate integration of other recommended or 36 required dental and/or medical services 37 12. Medical complications or underlying systemic conditions 38 13. Patient transferring to another provider during orthodontic treatment 39 14. Patient transferring from another provider where the previous treatment plan limits 40 the quality of outcome 41 15. Incomplete correction or relapse of orthognathic surgical procedures 42 43 Treatment Consultation and Informed Consent 44 45 A discussion must be held with the patient/parents/legal guardian utilizing lay terminology to 46 provide sufficient information for the responsible party to accept or reject the proposed treatment 47 plan. This discussion must be documented and should include: 48 49 1. A description of the diagnosis and treatment plan. 50 2. A discussion of reasonable alternative treatments.

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1 3. The relevant risks, compromises, and limitations associated with the proposed 2 treatment plan and alternative treatments. 3 4. A discussion of any portion of the treatment plan that will require the services of 4 other dental or medical health care providers and the anticipated effects of such 5 services on the orthodontic treatment plan. 6 5. The prognosis related to all treatment plans, including the option of no treatment. 7 6. A discussion of the patient's responsibility relating to the care (e.g., maintaining 8 periodic recall visits with their general dentist). 9 7. An estimate of the duration of active treatment and retention. 10 8. A signed agreement regarding informed consent and the financial arrangements 11 may be considered. 12 13 Risks Associated with Orthodontic Treatment 14 15 All forms of medical and dental treatment, including orthodontics, involve some risks and/or 16 limitations. Fortunately, in orthodontics, serious complications are infrequent. The orthodontist 17 should determine which potential risks to disclose to the patient in the exercise of sound 18 professional judgment given the clinical condition of the patient. Due to the length of orthodontic 19 treatment, conditions may arise which are coincident, but not caused by orthodontic treatment. 20 Some of the risks associated with orthodontic treatment include: 21 22 1. , or permanent markings (decalcification deca1cification). 23 2. The length of the roots of teeth may become shortened. This may be of no clinical 24 significance or may require the discontinuance of orthodontic treatment with 25 subsequent interdisciplinary treatment to stabilize the teeth. In some cases root 26 shortening may be pre-existing. 27 3. The health of the bone and periodontal support of the teeth may be affected. 28 4. The teeth and/or jaws have a tendency to change their positions after treatment. 29 5. Temporomandibular joint problems may appear concurrently with 30 orthodontic treatment, but may not be related to the treatment. 31 6. The vitality of a tooth may be compromised. 32 7. Orthodontic appliances may irritate or damage the oral tissues and may cause 33 injury if accidentally swallowed or aspirated. 34 8. Dental materials, instruments, and equipment may result in damage or injury to 35 the oral tissues, face and/or eyes. 36 9. Accidents during treatment or patient misuse of orthodontic appliances may result 37 in injury to the oral tissues, face and/or eyes. 38 10. Oral surgery, orthognathic surgery or other adjunctive medical, surgical or 39 dental procedures may be necessary in conjunction with orthodontic treatment. 40 Associated treatments carry additional risks which must be discussed with the 41 patient/parents/legal guardian by the health care practitioner providing the service. 42 11. Orthodontic appliances may cause attrition, flaking or fracturing of tooth 43 structure. 44 12. When orthodontic appliances are removed, fracture and/or damage to the teeth 45 may result. 46 13. Medical or psychosocial conditions may result in compromised results or 47 dissatisfaction with treatment. 48 14. Orthodontic materials may cause allergic reactions in some individuals. 49 15. Patients may be dissatisfied with their dental or facial esthetics at the conclusion 50 of treatment due to unrealistic expectations or perceptions. 51 16. Abnormal growth during or after treatment may produce undesirable results.

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1 17. Treatment time may be extended and results compromised due to unforeseen 2 circumstances and poor patient cooperation. 3 18. Tooth movement during orthodontics may be adversely affected for patients 4 receiving bisphosphonates. Bisphosphonates have the potential to slow tooth 5 movement and may lengthen treatment time. The effects of these medications may 6 be severe enough to stop tooth movement which may result in removal of 7 appliances regardless of tooth positions. The effects of bisphosphonates on an 8 individual are not predictable. Long-term bisphosphonate use has been observed to 9 decrease bone healing. It is possible that tooth movement and any surgery 10 procedures within the jaws or bone surrounding the teeth may be difficult, and in 11 some cases may result in osteonecrosis of the jaws. 12 19. The use of orally applied drugs, especially certain drugs of abuse such as cocaine 13 or amphetamines, may seriously compromise the gums and bone tissue around 14 teeth which can be exacerbated by orthodontic treatment. 15 16 Risks Associated with Adjunctive Procedures in Orthodontics 17 18 The orthodontist may recommend certain procedures that are intended to enhance or 19 facilitate the positive outcome of orthodontic therapy (i.e. temporary anchorage devices 20 devises, soft tissue laser treatment, etc.). These procedures may involve certain risks and 21 limitations, all of which may involve additional informed consent issues. 22 23 Post Treatment Evaluation and Outcomes Assessment 24 25 The effects of orthodontic treatment should be evaluated retrospectively with reference to the 26 pretreatment condition. Consistent re-evaluation of treatment results along with continued review 27 of treatment modalities and their effectiveness will serve to provide the public with the highest 28 quality of orthodontic care. Assessing the outcome of treatment is dependent upon the treatment 29 goals and objectives, the condition being treated, the stage of the patient's dentofacial 30 development, and the treatment provided. Limiting factors must be considered when evaluating 31 treatment and outcomes. 32 33 Post Treatment Records 34 35 Post treatment unaltered records provide information for the quantitative and qualitative 36 assessment of treatment changes as well as for education, research, and quality assurance. Post 37 treatment records may include, but are not limited to: 38 39 1. Extra and intraoral images (digital, still or video images) 40 2. Dental casts (hard copy or digital format) 41 3. Intraoral, panoramic, and/or cephalometric radiographs (CBCT as an alternative) 42 4. Other indicated procedures or tests 43 44 Positive Outcomes of Treatment 45 46 1. Satisfaction of the patient's chief complaint 47 2. Well aligned teeth 48 3. Good or improved occlusal function 49 4. Good or improved dental and facial esthetics 50 5. Good or improved environment for dentofacial development 51 6. Desirable modification of the size, shape, and position of the jaw(s)

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1 7. Stability of the treatment results 2 8. Good or improved dental and periodontal health 3 9. Good or improved temporomandibular function 4 5 Negative Outcomes of Treatment 6 7 1. The patient's chief complaint was not satisfied 8 2. Poorly aligned teeth 9 3. Poor or unimproved occlusal function 10 4. Poor or unimproved dental and facial esthetics 11 5. Premature root resorption (primary teeth) 12 6. Excessive root resorption (permanent teeth) 13 7. Loss of periodontal support 14 8. Clinically significant decalcification or dental caries 15 9. Unsatisfactory modification of the size, shape, and position of the jaws 16 10. Instability of the treatment results 17 11. Poor or worsened temporomandibular function 18 19 Retention 20 21 1. A retention plan must be established after reviewing the patient's original 22 condition, treatment objectives, the results achieved, and/or any limiting factors. 23 2. Completion of orthodontic treatment does not ensure the stability of the result. 24 Future treatment may be recommended when post treatment changes occur and 25 may be due to growth, maturation, aging, lack of compliance with the retention 26 protocol, periodontal problems, oral habits and post treatment trauma, among other 27 factors. 28 29 Record Keeping 30 31 The keeping and preserving of a patient's dental record is necessary to the goal of providing high 32 quality orthodontic treatment. Prudent record keeping is the foundation for planning and 33 maintaining the continuity of patient care. It also provides documentary evidence of the evaluation 34 and diagnosis of the patient's condition, the treatment plan, the treatment provided, referrals 35 made, and follow up care. It also documents communications with the patient, other health care 36 providers and any other third parties. The dental record also protects the legal interests of all 37 parties. In addition, a patient's dental record may provide material for continuing education, 38 research, administrative oversight, billing, and quality assurance. 39 40 1. Treatment procedures, changes in the treatment plan, patient compliance, 41 treatment difficulties, and other important aspects of treatment must be recorded 42 and maintained. Copies of related correspondence and appropriate release forms 43 must also be maintained as part of the patient's record. 44 2. Documentation must be written, dictated, or computer annotated; maintained 45 concurrently; and kept chronologically. 46 3. The original records are usually considered the property of the practitioner. Laws 47 regarding patient record access, duplication and transfer vary from state to state. 48 Practitioners can obtain clarification from their state regulatory agency. 49 4. Electronic/digital records have the potential to be altered. Alteration of original 50 electronic/digital records must be avoided. Credible computer software either 51 prevents this or records any alteration of an original electronic/digital record.

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1 However, enhancement of images is allowed as long as these are duly labeled and 2 saved as separate images. Enhancement of other electronic/digital records, such 3 as radiographs, to enable better identification of landmarks and/or dentoskeletal 4 anomalies is permissible; however, the original cannot be altered. It is the 5 responsibility of the practitioner to protect the sanctity of all patient records as 6 prescribed by all local, state and federal laws. 7 8 Transfer of Orthodontic Patients 9 10 Because of the time required to complete orthodontic treatment, the transfer of care from one 11 practitioner to another occurs frequently. 12 13 Recommendations to the Transferring Practitioner 14 15 1. Practitioners should attempt to arrange for the continuation of orthodontic treatment 16 of their patients with as little interruption as possible. Regardless of the reason for 17 transfer, reasonable efforts of both the transferring and accepting practitioner are 18 necessary to effect an orderly transfer. It is recommended, and in some states 19 required, to obtain a written release from the patient/parents/legal guardian prior to 20 the transfer of the patient's records. It is preferable to send copies of the pertinent 21 records directly to the new practitioner. The use of electronic media may facilitates 22 this process. It is acceptable, but less desirable, to provide these records to the 23 patient/ parents/legal guardian. A patient's records should not be withheld due to an 24 outstanding balance. 25 2. The transferring practitioner should ensure that all appliances are in good order. 26 The patient/parents/legal guardian should be advised that extended periods of 27 active orthodontic treatment without supervision can be detrimental, and an 28 appointment with the new practitioner should be scheduled as soon as possible. 29 3. The patient/parents/legal guardian should be informed that there may be different 30 approaches to treatment by different practitioners. 31 4. The patient/parents/legal guardian should be informed that there may be different 32 fees with treatment by different practitioners. 33 5. The transferring practitioner should make no statements that would undermine the 34 establishment of a sound doctor-patient relationship with the accepting practitioner. 35 6. The transferring practitioner should be available for consultation by the accepting 36 practitioner. 37 7. The transferring practitioner should provide appropriate financial information in 38 advance or immediately upon request to the accepting practitioner. 39 40 Recommendations to the Accepting Practitioner 41 42 1. The accepting practitioner should review the patient's records, including the 43 previous financial arrangements if available, prior to the development of a plan for 44 continuation of treatment. In addition, the estimated time required to complete 45 treatment and the financial arrangement for continuation of treatment should be 46 discussed as soon as possible. Patients should be informed about their present oral 47 health status without unprofessional comments about prior treatment. 48 2. Appropriate records documenting the status of the case at the time of transfer 49 should be made.

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1 3. A practitioner is not obligated to accept an orthodontic transfer patient. If a 2 practitioner is unable or unwilling to accept the transfer patient, the practitioner may 3 assist the patient/parents/legal guardian in finding another practitioner. 4 4. At the patient/parents/legal guardian's request, a practitioner may remove 5 appliances from a patient not of record. If appropriate, previous practitioners 6 should be consulted. 7 8 Patients Who Wish to Transfer because of Dissatisfaction with Current Orthodontist 9 10 Recommendations to the transferring practitioner 11 12 1. If it becomes known that a patient plans to leave an orthodontist’s practice for 13 another, the orthodontist should provide the name(s) of other orthodontists in the 14 area. 15 2. Upon the patient’s written request, copies of all treatment records and appropriate 16 financial records should be forwarded to the accepting orthodontist, or to the 17 patient, if requested. The original treating orthodontist should retain all original 18 records. A reasonable and fair fee can be charged for record duplication. Treatment 19 records cannot be withheld because the patient/guardian has an outstanding 20 balance. 21 22 Recommended procedures for accepting orthodontist 23 24 1. Check to verify the patient received a copy of “Advice for the transferring 25 orthodontic patient” form from the transferring orthodontist. If not, the patient should 26 be given a copy. 27 2. Request copies of all treatment records and appropriate financial records and the 28 AAO transfer form from the referring orthodontist. 29 3. Document thoroughly the patient’s condition on starting treatment in the practice. 30 4. Be candid in assessing treatment progress to date. The orthodontist should refrain 31 from any unnecessary remarks about the previous treatment that could be 32 construed as negative. 33 5. If unable or unwilling to accept transfer patients, consider referring the patient to 34 another AAO member. 35 36 Members should be aware of the following documents written by the AAO Legal Counsel: 37 38 1. Second Opinions 39 2. Terminating the Doctor/Patient Relationship 40 3. Patient Records and Record Keeping 41 42 43 Evidence-Based Dentistry 44 45 Definition 46 47 Evidence-based dentistry (EBD) is an approach to oral health care that requires the judicious 48 integration of systematic assessments of clinically relevant scientific evidence, relating to the 49 patient’s oral and medical condition and history, with the dentist’s clinical expertise and the 50 patient’s treatment needs and preferences. 51

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1 Levels of Evidence 2 3 Hierarchical rating systems exist to grade individual or multiple studies based on the type of study 4 design and effectiveness in answering a specific question. Evidence levels follow a structured 5 hierarchy of criteria for grading strength of evidence, and some include assessment of the study’s 6 methodological quality, precision of statistical data for the population being studied (internal 7 validity), and other considerations. 8 9 Examples of evidence ranging from a high to low-level: 10 11 Meta-analysis 12 Systematic Review 13 Randomized Trial 14 Cohort Study 15 Case/Control Study 16 Case Series 17 Expert Opinion 18 19 Best Evidence 20 21 The highest level of evidence available represents the current best evidence for a specific clinical 22 question. Based on a hierarchy of levels of evidence, meta-analysis and systematic reviews of 23 randomized controlled trials constitute the highest levels of current best evidence, and expert 24 opinion the lowest level of evidence. 25 26 Evidence-Based Clinical Recommendations 27 28 Evidence-Based clinical recommendations are developed through critical evaluation of the 29 collective body of evidence on a particular topic to provide practical applications of scientific 30 information that can assist orthodontists in clinical decision-making. In addition to scientific 31 journals, dental schools, and approved courses, sources of this information may be found in the 32 following locations: 33 34 1. Cochrane Collaboration 35 An international nonprofit organization that develops evidence-based systematic reviews 36 on health care interventions 37 2. MEDLINE™ 38 The National Library of Medicine's searchable database of over 12 million indexed citations 39 from more than 4,600 medical, dental, health and scientific journals Additional information 40 is available through the AAO Library. 41 42 HIPAA 43 44 The United States Department of Health and Human Services issued comprehensive privacy 45 regulations in December 2000 (modified in 2002 and 2003) which originated in the Health 46 Insurance Portability and Accountability Act of 1996 (HIPAA). The new rules are a set of federal 47 regulations that affects the practice of orthodontics. 48 49 Under the new rules, orthodontists may “use” and “disclose” a patient’s “protected health 50 information” only as the patient permits or as allowed under the privacy rules. Even where the use 51 and disclosure of such information is permissible, orthodontists must adopt policies and

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1 procedures to safeguard and limit the use and disclosure of the information to the “minimum 2 necessary” level required to accomplish the intended purpose of the use or disclosure. 3 4 In the context of this law, “protected health information” is “individually identifiable information” and 5 includes names, dates, phone/fax numbers, email addresses, home addresses, social security 6 numbers, and demographic data. Employment records are excluded from the definition unless 7 used in connection with the provision of treatment. 8 9 The use or disclosure of the information for any purpose requires the patient’s/guardians’ prior 10 written permission except for the purpose of the patient’s treatment, payments activities, and 11 “health care operations”, for the treatment activities of any health care provider, and for payment 12 activities of other covered entities such as insurance companies. 13 14 The privacy rules also give patients certain rights (amending their protected health information, the 15 right to an accounting of certain disclosures, etc.). According to the rule, the orthodontist needs to 16 appoint a “privacy official” within the practice and to adopt a privacy policy so internal changes can 17 be implemented and monitored in the practice. 18 19 The new security rules require persons and entities covered by HIPAA to assess the potential 20 risks to, and vulnerabilities of, their computer systems, protect against threats to information 21 security or integrity, implement and maintain security measures, and ensure compliance with 22 these safeguards. The specific security rules can be obtained here. at: 23 http://www.cms.hhs.gov/HIPAAGenInfo/Downloads/HIPAALaw.pdf 24 25 26 The privacy regulations only apply to health care providers who transmit (or authorize third party to 27 transmit on their behalf) protected health information electronically. The new regulations do not 28 apply to AAO members who transmit information in paper form or via facsimile. The new rules 29 require that appropriate administrative, technical and physical safeguards are put in place for 30 patients’ protection. The orthodontist must designate a privacy official who can develop and 31 implement the privacy procedures and a contact person who is responsible for receiving 32 complaints and can respond on matters concerning privacy. Orthodontists must provide privacy 33 training to their staff members within a reasonable amount of time after commencement of 34 employment and training should be documented. The privacy rules require that orthodontists 35 follow the “minimum necessary” rule (obligating practitioners to make reasonable efforts to use, 36 disclose, and obtain the minimum amount of protected information reasonably required to achieve 37 the intended purpose) in relation to the use and disclosure of protected patient information, and 38 reasonably safeguard such information to limit incidental uses and disclosures. 39 40 The AAO website provides further details on the need for a written consent to use protected 41 information for treatment, payment or health care operations. The website also details what the 42 consent form should contain, what new rights are given to patients by the new rules, information 43 concerning the extent of the accounting of disclosure that must be given, information about the 44 type of privacy notice that must be given, and when written authorization from the patient/guardian 45 must be obtained. Practitioners are encouraged to consult the AAO HIPAA Compliance Manual 46 found on the AAO website (http://www.aaomembers.org/legal/hipaa). 47

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1 Appendix A 2 3 Historical Development 4 5 At its November 1993 meeting, the AAO Board of Trustees directed the AAO Council on 6 Orthodontic Health Care (COHC) to study the feasibility of developing clinical practice guidelines 7 for orthodontics. The council met in January 1994 and proposed a business plan for the 8 development of Guidelines, which was considered at the February 1994 meeting of the AAO 9 Board of Trustees. It was the consensus of the AAO Board of Trustees to develop guidelines 10 utilizing the expertise within the AAO. A task force was appointed. (Appendix A) 11 12 The task force met three times between July 1994 and January 1995 and wrote draft guidelines. A 13 copy of draft guidelines was sent to all active AAO members in April 1995 for review. Open forums 14 were held at the 1995 AAO Annual Session and at the meetings of all eight AAO constituent 15 societies during August-November 1995. The task force met again in December 1995 to revise the 16 draft guidelines based on feedback received in 1995. The December 1995 revised draft guidelines 17 were widely circulated in January 1996 for comment. The task force reviewed the comments and a 18 revised draft of the guidelines was distributed to the AAO House of Delegates members, the Board 19 of Trustees and other leaders of organized orthodontics in April 1996. An open forum was held at 20 the 1996 AAO Annual Session for comments on the revised draft guidelines. The revised draft 21 guidelines were approved by the Board of Trustees, a House of Delegates Reference Committee 22 and by the House of Delegates. The Clinical Practice Guidelines were printed in 1996 and were 23 made available to AAO members. 24 25 A reprint of the 1996 Clinical Practice Guidelines was published in 2001. 26 27 The Board of Trustees decided at their May 2007 meeting to appoint a task force to review and 28 recommend changes to the AAO document “Clinical Practice Guidelines for Orthodontics and 29 Dentofacial Orthopedics 2001.” The 2008 Guidelines will be made available on the AAO members’ 30 website so they will be more easily accessible. The task force was also asked to recommend a 31 protocol to regularly update these Guidelines. 32 33 The task force members were assigned in September 2007 (Appendix C). Conference calls and 34 emails between November 2007 and June 2008 were used to make edits and additions to the 35 2001 Clinical Practice Guidelines. When all changes have been fully discussed and agreed upon 36 by the task force members, they will be circulated to all AAO Councils for input. The task force will 37 then consider whether or not any additional changes are to be made prior to approval by legal 38 counsel and the Board of Trustees. 39 40

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1 Appendix B 2 3 Updating of Clinical Practice Guidelines 4 5 The American Association of Orthodontists considers its Clinical Practice Guidelines to be a living 6 document. The existence of this document is intended to stimulate improvement in the practice of 7 orthodontics by identifying areas where knowledge is incomplete or inadequate. The AAO 8 recognizes the dynamic nature of orthodontics and dentofacial orthopedics and the necessity for 9 updating the guidelines to reflect the evolving science and art of orthodontics. 10 11 Revisions to the document, with opportunities for AAO member input, will be made to reflect 12 increasing knowledge and experience. This will take into account future practice developments, 13 basic science and clinical research findings, and clinical data on treatment outcomes. In this 14 manner, the guidelines will continue to evolve and serve as an important resource to the dental 15 profession. 16 17 The AAO is committed to revising this document biennially. The AAO President will select an AAO 18 Board member to chair the task force. One council member from three councils will be appointed 19 to the taskforce. Councils providing members to the taskforce will rotate each time the guidelines 20 are updated. An AAO staff member will also be appointed to the task force. The AAO Board of 21 Trustees task force will be authorized to make minor revisions from time to time. The Clinical 22 Practice Guidelines will be an online document only. 23 24 25

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1 Appendix C – Clinical Practice Guidelines Task Force Members 2 3 1994 Task Force Members 4 5 Dr. Charles S. Tjersland, Chairman 6 Dr. Rolf G. Behrents 7 Dr. Thomas J. Cangialosi 8 Dr. Rodney C. Dubois 9 Dr. Raymond George, Sr. 10 Dr. Arnold J. Hill 11 Dr. Laurance E. Jerrold 12 Dr. Terry R. Pracht 13 Dr. Donald R. Poulton, Trustee Liaison 14 Mr. Terry G. Wolf, Staff Liaison 15 16 2007 Task Force Members 17 18 Dr. David Turpin, Chair and Trustee Liaison 19 Dr. Michael Foy 20 Dr. Jeffery Johnson 21 Dr. Douglas Klein 22 Dr. Gary Opin 23 Dr. Robert Prince 24 Dr. O.H. Rigsbee 25 Dr. Emile Rossouw 26 Dr. Bhavna Shroff 27 Ms. Jackie Hittner, AAO Staff Liaison 28 29 2013 Committee Members 30 31 Dr. Christopher Roberts, Chair and Trustee Liaison 32 Dr. Carolyn Melita (COOP) 33 Dr. Shannon Owens (COSA) 34 Dr. Sheldon Seidel (COE) 35 Ms. Jackie Hittner, AAO Staff Liaison

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1 Selected References 2 3 ‘*’ – denotes reference could not be verified. 4 5 Introduction 6 7 American Academy of Periodontology. Guidelines for periodontal therapy. Chicago: American 8 Academy of Periodontology; 1993. 9 10 American Association of Endodontists. Appropriateness of care and quality assurance guidelines 11 of the American Association of Endodontists. Chicago: American Association of Endodontists; 12 1994. 13 14 American Association of Oral and Maxillofacial Surgeons. Parameters of care for oral and 15 maxillofacial surgery. A guide for practice, monitoring and evaluation (AAOMS Parameters of Care 16 92). Journal of Oral and Maxillofacial Surgery 1992;50(7 Suppl 2) : i-xvi, 1-174. 17 18 American Association of Orthodontists. American Association of Orthodontists bylaws and 19 principles of ethics. St. Louis: American Association of Orthodontists; 1994. 20 21 American Association of Orthodontists. Glossary of dentofacial orthopedic terms. St. Louis: 22 American Association of Orthodontists; 1993. 23 24 American Association of Orthodontists. Guidelines for quality assessment of orthodontic care. St. 25 Louis: American Association of Orthodontists; 1988. 26 27 American Dental Association. Standards for advanced specialty education programs in 28 orthodontics. Chicago: American Dental Association; 1991. 29 30 Field MJ, Lohr KN. Guidelines for clinical practice: from development to use. Washington, DC: 31 National Academy Press; 1992. 32 33 ICD-9-CM: the International classification of diseases, 9th revision, clinical modification. 4th ed. 34 New York: McGraw-Hill; 1995. 35 36 Lovelace SE. Guiding the profession. CDA Journa1 of the California Dental Association 37 1993;21:30-6. 38 39 Pretreatment Considerations 40 41 Ackerman JL, Proffit WR. The characteristics of malocclusion: a modern approach to classification 42 and diagnosis. American Journal of Orthodontics 1969;56:443-54. 43 44 *Albino JE. Psychosocial aspects of malocclusion. New York: Behavioral Health; 1984. p. 918-26. 45 Baumrind S, Frantz RC. The reliability of head film measurements. American Journal of 46 Orthodontics 1971;60:111-27. 47 48 Bottomly WK. Patient health status evaluation procedures for the dental profession. Part I - 49 Dental/medical history. Journal of Oral Medicine 1976;Spec. No:5-7. 50

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1 Burstone CJ. Application of bioengineering to clinical orthodontics. In: Graber TM, Vanarsdall RL. 2 Orthodontics: current principles and techniques. 2nd ed. St. Louis: Mosby; 1994. p. 235-267. 3 4 Dale JG. Interceptive guidance of occlusion, with emphasis on diagnosis. In: Graber TM, 5 Vanarsdall RL. Orthodontics: current principles and techniques. 2nd ed. St. Louis: Mosby; 1994. p. 6 291-379. 7 8 Downs WB. The role of cephalometrics in orthodontic case analysis and diagnosis. American 9 Journal of Orthodontics 1952;38:162-82. 10 11 Forsberg CT, Burstone CJ, Hanley KJ. Diagnosis and treatment planning of skeletal asymmetry 12 with the submental-vertical radiograph. American Journal of Orthodontics 1984;85:224-37. 13 14 Graber TM. Panoramic radiography in orthodontic diagnosis. American Journal of Orthodontics 15 1967;53:799-821. 16 17 Grave KC, Brown T. Carpal radiographs in orthodontic treatment. American Journal of 18 Orthodontics 1979;75:27-45. 19 20 Greulich WW, Pyle SI. Radiographic atlas of skeletal development of the hand and wrist. 2nd ed. 21 Stanford, CA: Stanford University Press; 1959. 22 23 Horowitz SL, Hixon EH. The nature of orthodontic diagnosis. St. Louis: C.V. Mosby Co.; 1966. 24 25 Kaplan RG. Standardization for serial intraoral photography. American Journal of Orthodontics 26 1979;75:431-7. 27 28 Kenealy P, Frude N, Shaw W. An evaluation of the psychological and social effects of 29 malocclusion: some implications for dental policy making. Social Science and Medicine 30 1989;28:583-91. 31 32 Kenealy P, Hackett P, Frude N, Lucas P, Shaw W. The psychological benefit of orthodontic 33 treatment. Its relevance to dental health education. New York State Dental Journal 1991;57:32-4. 34 35 Larheim TA, Svanaes DB. Reproducibility of rotational panoramic radiography: mandibular linear 36 dimensions and angles. American Journal of Orthodontics and Dentofacial Orthopedics 37 1986;90:45-51. 38 39 Macgregor FC. Social and psychological implications of dentofacial disfigurement. Angle 40 Orthodontist 1970;40:231-3. 41 42 McLain JB, Proffit WR. Oral health status in the United States: prevalence of malocclusion. 43 Journal of Dental Education 1985;49:386-97. 44 45 Moyers RE. Standards of human occlusal development. Craniofacial growth series No. 5 Ann 46 Arbor, MI: Center for Human Growth and Development, University of Michigan; 1976. 47 48 Proffit WR, Ackerman JL. Diagnosis and treatment planning in orthodontics. In: Graber TM, 49 Vanarsdall RL. Orthodontics: current principles and techniques. 2nd ed. St. Louis: Mosby; 1994. p. 50 3-95. 51

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1 Richmond S. Recording the dental cast in three dimensions. American Journal of Orthodontics 2 and Dentofacial Orthopedics 1987;92:199-206. 3 4 Ricketts RM. Perspectives in the clinical application of cephalometrics. The first fifty years. Angle 5 Orthodontist 1981;51:115-50. 6 7 Riedel RA. An analysis of dentofacial relationships. American Journal of Orthodontics 8 1957;43:103-19. 9 10 Riolo ML, Moyers RE, McNamara JA Jr, Hunter WS. An Atlas of craniofacial growth. Craniofacial 11 growth series No. 2 Ann Arbor, MI: Center for Human Growth and Development, University of 12 Michigan; 1974. 13 14 Romriell GE, Streeper SN. The medical history. Dental Clinics of North America 1982;26:3-11. 15 16 Shaw WC. The influence of children's dentofacial appearance on their social attractiveness as 17 judged by peers and lay adults. American Journal of Orthodontics 1981;79:399-415. 18 19 Shaw WC, Meek SC, Jones DS. Nicknames, teasing. harassment and the salience of dental 20 features among school children. British Journal of Orthodontics 1980;7:75-80. 21 22 Steiner CC. Cephalometries in clinical practice. Angle Orthodontist 1959;29:8-29. 23 24 Stutts WF. Clinical photography in orthodontic practice. American Journal of Orthodontics 25 1978;74:1-31. 26 27 Terezhalmy GT, Schiff T. The historical profile. Dental Clinics of North America 1986;30:357-68. 28 29 Vanarsdall RL, Musich DR. Adult orthodontics: diagnosis and treatment. In: Graber TM, Vanarsdall 30 RL. Orthodontics: current principles and techniques. 2nd ed. St. Louis: Mosby; 31 1994. p. 750-834. 32 33 Walker RP. Computer applications in orthodontics. In: Graber TM, Vanarsdall RL. Orthodontics: 34 current principles and techniques. 2nd ed. St. Louis: Mosby; 1994. p. 268-290. 35 36 Diagnosis and Treatment 37 38 Anomalies of Jaw Size, Relationship of Jaw to Cranial Base, Dental Arch Relationship and Dental 39 Alveolus 40 41 Alexander RG, Sinclair PM, Goates LJ. Differential diagnosis and treatment planning for the adult 42 nonsurgical orthodontic patient. American Journal of Orthodontics 1986;89:95-112. 43 44 Arvystas MG. Treatment of anterior skeletal open-bite deformity. American Journal of Orthodontics 45 1977;72:147-64. 46 47 Barrer HG. The adult orthodontic patient. American Journal of Orthodontics 1977;72:617-40. 48 49 Bell WH, Jacobs JD, Legan HL. Treatment of Class II deep bite by orthodontic and surgical 50 means. American Journal of Orthodontics 1984;85:1-20. 51

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1 Bell WH, Jacobs JD, Quejada JG. Simultaneous repositioning of the maxilla mandible and chin. 2 Treatment planning and analysis of soft tissues. American Journal of Orthodontics and Dentofacial 3 Orthopedics 1986;89:28-50. 4 5 Bishara SE, Staley RN. Maxillary expansion: clinical implications. American Journal of 6 Orthodontics and Dentofacial Orthopedics 1987;91:3-14. 7 8 Burstone CR. Deep overbite correction by . American Journal of Orthodontics 1977;72:1- 9 22. 10 11 Cangialosi TJ, Meistrell ME Jr, Leung MA, Ko JY. A cephalometric appraisal of edgewise Class II 12 nonextraction treatment with extraoral force. American Journal of Orthodontics and Dentofacial 13 Orthopedics 1988;93:315-24. 14 15 Cangialosi TJ. Skeletal morphologic features of anterior open bite. American Journal of 16 Orthodontics 1984;85:28-36. 17 18 Carlotti AE, George R. Differential diagnosis and treatment planning of the surgical orthodontic 19 class III malocclusion. American Journal of Orthodontics 1981;79:424-36. 20 21 Case CS. The question of extraction in orthodontia. American Journal Orthodontics 1964;50:660- 22 91. 23 24 Chaconas SJ, de Alba y Levy JA. Orthopedic and orthodontic applications of the quad-helix 25 appliance. American Journal of Orthodontics 1977;72:422-8. American Journal of Orthodontics 26 and Dentofacial Orthopedics 27 28 Epker BN, Fish L. Surgical-orthodontic correction of open-bite deformity. American Journal of 29 Orthodontics 1977;71:278-99. 30 31 Epker BN, Wolford LM, Fish LC. Mandibular deficiency syndrome II. Surgical considerations for 32 mandibular advancement. Oral Surgery, Oral Medicine, and Oral Pathology 1978;45:349-63. 33 34 Frankel R, Frankel C. A functional approach to treatment of skeletal open bite. American Journal 35 of Orthodontics 1983;84:54-68. 36 37 Gianelly AA, Arena SA, Bernstein L. A comparison of Class II treatment changes noted with the 38 light wire, edgewise, and Frankel appliances. American Journal of Orthodontics 1984;86:269-76. 39 40 Glassman AS, Nahigian SJ, Medway JM, Aronowitz HI. Conservative surgical orthodontic adult 41 rapid : sixteen cases. American Journal of Orthodontics 1984;86:207-13. 42 43 Glenn G, Sinclair PM, Alexander RG. Nonextraction orthodontic therapy: posttreatment dental and 44 skeletal stability. American Journal of Orthodontics and Dentofacial Orthopedics 1987;92:321-8. 45 46 Graber LW. Chin cup therapy for mandibular . American Journal of Orthodontics 47 1977;72:23-41. 48 49 Graber TM. Functional appliances. In: Graber TM, Vanarsdall RL. Orthodontics: current principles 50 and techniques. 2nd ed. St. Louis: Mosby; 1994. p. 383-436. 51

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1 Holdaway RA. A soft-tissue and its use in orthodontic treatment planning. 2 Part II. American Journal of Orthodontics 1984;85:279-93. 3 4 Jacobson A. The “Wits” appraisal of jaw disharmony. American Journal of Orthodontics 5 1975;67:125-38. 6 7 Magness WB. The mini-visualized treatment objective. American Journal of Orthodontics and 8 Dentofacial Orthopedics 1987;91:361-74. 9 10 Moyers RE, Bookstein, FL, Hunter, WS. Section II: Diagnosis. In: Moyers RE. Handbook of 11 orthodontics. 4th ed. Chicago: Year Book Medical Publishers; 1988. p. 165-301. 12 13 McNamara JA Jr, Huge SA. The (FR2): model preparation and appliance 14 construction. American Journal of Orthodontics 1981;80:478-95. 15 16 McNamara JA Jr. An orthopedic approach to the treatment of Class III malocclusion in young 17 patients. Journal of Clinical Orthodontics 1987;21:598-608. 18 19 McNamara JA. Mixed dentition treatment. In: Graber TM, Vanarsdall RL. Orthodontics: current 20 principles and techniques. 2nd ed. St. Louis: Mosby; 1994. p. 507-541. 21 22 Nahoum HI. Vertical proportions: a guide for prognosis and treatment in anterior open-bite. 23 American Journal of Orthodontics 1977;72:128-46. 24 25 Pancherz H. A cephalometric analysis of skeletal and dental changes contributing to Class II 26 correction in activator treatment. American Journal of Orthodontics 1984;85:125-34. 27 28 Pearson LE. Vertical control in fully-banded orthodontic treatment. Angle Orthodontist 29 1986;56:205-24. 30 31 Pearson LE. Treatment of a severe openbite excessive vertical pattern with an eclectic non- 32 surgical approach. Angle Orthodontist 1991;61:71-6. 33 34 Pfeiffer JP, Grobety D. A philosophy of combined orthopedic-orthodontic treatment. American 35 Journal of Orthodontics 1982;81:185-201. 36 37 Poulton DR, Ware WH. Increase in mandibular and chin projection with orthognathic surgery. 38 American Journal of Orthodontics 1985;87:363-76. 39 40 Proffit WR, Ackerman JL. Diagnosis and treatment planning in orthodontics. In: Graber TM, 41 Vanarsdall RL. Orthodontics: current principles and techniques. 2nd ed. St. Louis: Mosby; 1994. p. 42 3-95. 43 44 Proffit WR, Ackerman JL, Fields HW. Section III: Diagnosis and treatment planning. In: Proffit WR. 45 Contemporary orthodontics. 2nd ed. St. Louis: Mosby-Year Book; 1993. p. 139-264. 46 47 Richardson ER. Racial differences in dimensional traits of the human face. Angle Orthodontist 48 1980;50:301-11. 49 50 Riedel RA. An analysis of dentofacial relationships. American Journal of Orthodontics 51 1957;43:103-19.

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1 Roth RH. The straight-wire appliance 17 years later. Journal of Clinical Orthodontics 1987;21:632- 2 42. 3 4 Sakamoto T. Effective timing for the application of orthopedic force in the skeletal class III 5 malocclusion. American Journal of Orthodontics 1981;80:411-6. 6 7 Skieller V, Bjork A, Linde-Hansen T. Prediction of mandibular growth rotation evaluated from a 8 longitudinal implant sample. American Journal of Orthodontics 1984;86:359-70. 9 10 Stockli PW, Teuscher UM. Combined activator headgear orthopedics. In: Graber TM, Vanarsdall 11 RL. Orthodontics: current principles and techniques. 2nd ed. St. Louis: Mosby; 1994. p. 437-506. 12 13 Turpin DL. Befriend your oral and maxillofacial radiologist. American Journal of Orthodontics and 14 Dentofacial Orthopedics 2007;131:697. 15 16 Wendell PD, Nanda R, Sakamoto T, Nakamura, S. The effects of chin cup therapy on the 17 mandible: a longitudinal study. American Journal of Orthodontics 1985;87:265-74. 18 19 Wieslander L. Intensive treatment of severe Class II with headgear-Herbst 20 appliance in the early mixed dentition. American Journal of Orthodontics 1984:86:1-13. 21 22 Wieslander L, Lagerstrom L. The effect of activator treatment on class II malocclusions. American 23 Journal of Orthodontics 1979;75:20-6. 24 25 Williams S, Andersen CE. The morphology of the potential Class III skeletal pattern in the growing 26 child. American Journal of Orthodontics 1986;89:302-11. 27 28 Zachrisson BU. Bonding in orthodontics. In: Graber TM, Vanarsdall RL. Orthodontics: current 29 principles and techniques. 2nd ed. St. Louis: Mosby; 1994. p. 542-626. 30 31 Anomalies of Tooth Position, Discrepancies of Tooth Size and Arch Length 32 33 Bishara SE, Staley RN. Maxillary expansion: clinical implications. American Journal of 34 Orthodontics and Dentofacial Orthopedics 1987;91:3-14. 35 36 Bolton WA. Disharmony in tooth size and its relation to the analysis and treatment of malocclusion. 37 Angle Orthodontist 1958;28:113-30. 38 39 Bolton WA. The clinical application of a tooth-size analysis. American Journal Orthodontics 40 1962;48:504-29. 41 42 Clark JD, Williams JK. The management of spacing in the maxillary region. British Journal 43 of Orthodontics 1978;5:35-9. 44 45 Dale JG. Interceptive guidance of occlusion, with emphasis on diagnosis. In: Graber TM, 46 Vanarsdall RL. Orthodontics: current principles and techniques. 2nd ed. St. Louis: Mosby; 1994. p. 47 291-379. 48 49 Dewel BF. Serial extraction in orthodontics: indications, objectives, and treatment procedures. 50 American Journal of Orthodontics 1954;40:906-26. 51

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1 American Journal of Orthodontics and Dentofacial Orthopedics 1991;100:494-512. 2 3 Dentofacial Functional Abnormalities 4 5 American Association of Orthodontists House of Delegates. Resolution Number 58-93, May 1993. 6 7 American Association of Orthodontists. Glossary of dentofacial orthopedic terms. St. Louis: 8 American Association of Orthodontists; 1993. 9 10 Andrianopoulos MV, Hanson ML. Tongue-thrust and the stability of overjet correction. Angle 11 Orthodontist 1987;57:121-35. 12 13 Baumrind S, Korn EL, Isaacson RJ, West EE, Molthen R. Superimpositional assessment of 14 treatment-associated changes in the temporomandibular joint and the mandibular symphysis. 15 American Journal of Orthodontics 1983;84:443-65. 16 17 Behrents RG, White RA. TMJ research: responsibility and risk. American Journal of Orthodontics 18 and Dentofacial Orthopedics 1992;101:1-3. 19 20 Bushey RS. Adenoid obstruction of the nasopharynx. In: Moyers RE, McNamara, JA, Ribbens, 21 KA. Naso-respiratory function and craniofacial growth: this volume includes the proceedings of a 22 sponsored symposium, honoring Professor Robert E. Moyers held February 23 and 24, 1979, in 23 Ann Arbor, Michigan. Craniofacial growth series No. 9 Ann Arbor, MI: Center for Human Growth 24 and Development, University of Michigan; 1979. p. 199-232. 25 26 Dibbets JM, van der Weele LT. The prevalence of joint noises as related to age and gender. 27 Journal of Craniomandibular Disorders 1992;6:157-60. 28 29 Fields HW, Warren DW, Black K, Phillips CL. Relationship between vertical dentofacial 30 morphology and respiration in adolescents. American Journal of Orthodontics and Dentofacial 31 Orthopedics 1991;99:147-54. 32 33 Graber TM. The “three M's”: Muscles, malformation, and malocclusion. American Journal 34 Orthodontics 1963;49:418-50. 35 36 Graber TM. Postmortems in posttreatment adjustment. American Journal of Orthodontics 37 1966;52:331-52. 38 39 Grummons D. Orthodontics for the TMJ-TMD patient. Scottsdale, Ariz.: Wright, & Co. Publishers; 40 1994. 41 42 Harvold EP, Tomer BS, Vargervik K, Chierici G. Primate experiments on oral respiration. American 43 Journal of Orthodontics 1981;79:359-72. 44 45 Haryett RD, Hansen FC, Davidson PO. Chronic thumb sucking. A second report on treatment and 46 its psychological effects. American Journal of Orthodontics 1970;57:164-78. 47 48 Ingervall B. Orthodontic treatment in adults with temporomandibular dysfunction symptoms. 49 American Journal of Orthodontics 1978;73:551-9. 50

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1 Jones AG, Bhatia S. A study of nasal respiratory resistance and craniofacial dimensions in white 2 and West Indian black children. American Journal of Orthodontics and Dentofacial Orthopedics 3 1994;106:34-9. 4 5 Kerr WJ, McWilliam JS, Linder-Aronson S. Mandibular form and position related to changed mode 6 of breathing- a five-year longitudinal study. Angle Orthodontist 1989;59:91-6. 7 8 Larsson EF, Dahlin KG. The prevalence and the etiology of the initial dummy- and finger-sucking 9 habit. American Journal of Orthodontics 1985;87:432-5. 10 11 Linder-Aronson S. Adenoids. Their effect on mode of breathing and nasal airflow and their 12 relationship to characteristics of the facial skeleton and the denition. A biometric, rhino-manometric 13 and cephalometro-radiographic study on children with and without adenoids. Acta Oto- 14 Laryngologica. Supplement (Oslo) 1970;265:1-132. 15 16 Linder-Aronson S. Effects of adenoidectomy on dentition and nasopharynx. Transactions. 17 European Orthodontic Society 1972;177-86. 18 19 Linder-Aronson S, Leighton BC. A longitudinal study of the development of the posterior 20 nasopharyngeal wall between 3 and 16 years of age. European Journal of Orthodontics 21 1983;5:47-58. 22 23 Linder-Aronson S, Woodside DG, Hellsing E, Emerson W. Normalization of incisor position after 24 adenoidectomy. American Journal of Orthodontics and Dentofacial Orthopedics 1993;103:412-27. 25 26 Mason RM. Orthodontic perspectives on orofacial myofunctional therapy. International Journal of 27 Oral and Maxillofacial Surgery 1988;14:49-55. 28 29 McNeill C. Craniomandibular disorders: guidelines for evaluation, diagnosis, and management. 30 Chicago: Quintessence Publishing Company; 1990. 31 32 Morgan DH, Hall WP, Vamvas SJ. Diseases of the temporomandibular apparatus: a 33 multidisciplinary approach. St. Louis: Mosby, 1977. 34 35 Moss JP. The soft tissue environment of teeth and jaws. An experimental and clinical study: part 1. 36 British Journal of Orthodontics 1980;7:107-37. 37 38 Niinimaa V, Cole P, Mintz S, et al. Oronasal distribution of respiratory airflow. Respiration 39 Physiology 1981;43:69-75. 40 41 Proffit WR. Lingual pressure patterns in the transition from tongue thrust to adult swallowing. 42 Archives of Oral Biology 1972;17:555-63. 43 44 Roth RH. Functional occlusion for the orthodontist. Part III. Journal of Clinical Orthodontics 1981; 45 15:174-9, 182-98. 46 47 Sadowsky S, BeGole EA. Long-term status of temporomandibular joint function and functional 48 occlusion after orthodontic treatment. American Journal of Orthodontics 1980;78:201-12. 49

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1 Stringert HG, Worms FW. Variations in skeletal and dental patterns in patients with structural and 2 functional alterations of the temporomandibular joint: a preliminary report. American Journal of 3 Orthodontics 1986; 89:285-97. 4 5 Subtelny JD. Oral habits - studies in form, function and therapy. Angle Orthodontist 1973;43:349- 6 83. 7 8 Tamari K, Murakami T, Takahama Y. The dimensions of the tongue in relation to its motility. 9 American Journal of Orthodontics and Dentofacial Orthopedics 1991;99:140-6. 10 11 Vig KW. Orthodontic considerations applied to craniofacial dysmorphology. Cleft Palate Journal 12 1990;27:141-5. 13 14 Vig PS, Sarver DM, Hall DJ, Warren DW. Quantitative evaluation of nasal airflow in relation to 15 facial morphology. American Journal of Orthodontics 1981;79:263-72. 16 17 Vig PS, Showfety KJ, Phillips C. Experimental manipulation of head posture. American Journal of 18 Orthodontics 1980;77:258-68. 19 20 Watson RM Jr, Warren DW, Fischer ND. Nasal resistance, skeletal classification and mouth 21 breathing in orthodontic patients. American Journal of Orthodontics 1968;54:367-79. 22 23 Williamson EH. Temporomandibular dysfunction in pretreatment adolescent patients. American 24 Journal of Orthodontics 1977;72:429-33. 25 26 Craniofacial Anomalies, Cleft Lip and Palate 27 28 American Cleft Palate-Craniofacial Association. Parameters for evaluation and treatment of 29 patients with cleft lip/palate or other craniofacial anomalies. Cleft Palate Craniofacial Journal 30 1993;30 Suppl:S1-16. 31 32 Gorlin RJ, Pindborg JJ. Syndromes of the head and neck. New York: McGraw-Hill; 1964. 33 34 Graber TM. Craniofacial morphology in cleft palate and cleft lip deformities. Surgery, Gynecology 35 and Obstetrics 1949;88:359-69. 36 37 Horowitz SL, Hixon EH. The nature of orthodontic diagnosis. St. Louis: C.V. Mosby Co.; 1966. 38 39 Iyer VS, Desai DM. Acceptable deviations in normal dentitions. Angle Orthodontist 1963;33:253-7. 40 41 Jacobson BN, Rosenstein SW. Early maxillary orthopedics for the newborn cleft lip and palate 42 patient. An impression and an appliance. Angle Orthodontist 1984;54:247-63. 43 44 Johnson AL. Basic principles of orthodontia. Dental Cosmos 1923;65:503-518. 45 46 Kernahan DA, Rosenstein SW. Cleft lip and palate: a system of management. Baltimore: Williams 47 & Wilkins, 1990. 48 49 Moyers RE. Standards of human occlusal development. Craniofacial growth series No. 5 Ann 50 Arbor, MI: Center for Human Growth and Development, University of Michigan; 1976. 51

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1 Popovich F, Thompson GW. Craniofacial templates for orthodontic case analysis. American 2 Journal of Orthodontics 1977;71:406-20. 3 4 Rollnick BR, Pruzansky S. Genetic services at a center for craniofacial anomalies. Cleft Palate 5 Journal 1981;18:304-13. 6 7 Rosenstein SW. Early habilitation of the cleft lip and palate child. In: Johnston LE. New vistas in 8 orthodontics. Philadelphia: Lea & Febiger; 1985. p. 320-40. 9 10 Ross RB. Treatment variables affecting facial growth in complete unilateral cleft lip and palate. 11 Cleft Palate Journal 1987;24:5-77. 12 13 Shprintzen RJ, Siegel-Sadewitz VL, Amato J, Goldberg RB. Anomalies associated with cleft lip, 14 cleft palate, or both. American Journal of Medical Genetics 1985;20:585-95. 15 16 Turvey TA, Vig K, Moriarty J, Hoke J. Delayed bone grafting in the cleft maxilla and palate: a 17 retrospective multidisciplinary analysis. American Journal of Orthodontics 1984;86:244-56. 18 19 Vig KW, Turvey TA. Orthodontic-surgical interaction in the management of cleft lip and palate. 20 Clinics in Plastic Surgery 1985;12:735-48. 21 22 Treatment Objectives and Limiting Factors 23 24 Bolton WA. Disharmony in tooth size and its relation to the analysis and treatment of malocclusion. 25 Angle Orthodontist 1958;28:113-30. 26 27 Gianelly AA, Arena SA, Bernstein L. A comparison of Class II treatment changes noted with the 28 light wire, edgewise, and Frankel appliances. American Journal of Orthodontics 1984;86:269-76. 29 30 Graber TM, Vanarsdall RL. Orthodontics: current principles and techniques. 2nd ed. St. Louis: 31 Mosby; 1994. 32 33 Little RM, Riedel RA, Artun J. An evaluation of changes in mandibular anterior alignment from 10 34 to 20 years postretention. American Journal of Orthodontics and Dentofacial Orthopedics 35 1988;93:423-8. 36 37 Little RM. Stability and relapse of dental arch alignment. British Journal of Orthodontics 38 1990;17:235-41. 39 40 Nance HN. The limitations of orthodontic treatment: I. Mixed dentition diagnosis and treatment. 41 American Journal of Orthodontics and Oral Surgery 1947;33:177-223. 42 43 Nance HN. The limitations of orthodontic treatment: II. Diagnosis and treatment in the permanent 44 dentition. American Journal of Orthodontics and Oral Surgery 1947;33:253-301. 45 46 Proffit WR. Contemporary orthodontics. 2nd ed. St. Louis: Mosby-Year Book; 1993. 47 Sharpe W, Reed B, Subtelny JD, Polson A. Orthodontic relapse, apical root resorption, and crestal 48 alveolar bone levels. American Journal of Orthodontics and Dentofacial Orthopedics 1987;91:252- 49 8. 50

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1 Strang RHW. Conditions influencing the prognosis. In: Strang RHW. A textbook of Orthodontia. 2 2nd ed. Philadelphia: Lea & Febiger; 1943. p. 233-5. 3 4 Tirk TM. Limitations in orthodontic treatment. Angle Orthodontist 1965;35:165-77. 5 6 van der Linden FPGM. Over de achtergronden van success en mislukking bij de behandeling van 7 angle klasse II/I-afwijkingen [Success and Failures after Treatment of Angle Class II/I Anomalies]. 8 Nederlands Tijdschrift voor Tandheelkunde 1964;71:505-20. [Dutch] 9 10 *van der Linden FPGM. Possibilities and Limitations of Orthodontic Appliances. Studieweek, 1965. 11 12 Treatment Consultation and Informed Consent 13 14 Artun J. Caries and periodontal reactions associated with long-term use of different types of 15 bonded lingual retainers. American Journal of Orthodontics 1984;86:112-8. 16 17 Copeland S, Green LJ. Root resorption in maxillary central incisors following active orthodontic 18 treatment. American Journal of Orthodontics and Dentofacial Orthopedics 1986;89:51-5. 19 20 Davidson WM, Sheinis EM, Shepherd SR. Tissue reaction to orthodontic adhesives. American 21 Journal of Orthodontics 1982;82:502-7. 22 23 Geiger AM. Mucogingival problems and the movement of mandibular incisors: a clinical 24 review. American Journal of Orthodontics 1980;78:511-27. 25 26 Gorelick L, Geiger AM, Gwinnett AJ. Incidence of white spot formation after bonding and banding. 27 American Journal of Orthodontics 1982;81:93-8. 28 29 Graber TM, Vanarsdall RL. Orthodontics: current principles and techniques. 2nd ed. St. Louis: 30 Mosby; 1994. 31 32 Horowitz SL, Hixon EH. Norms, classification, and treatment goals. In: Horowitz SL, Hixon EH. 33 The nature of orthodontic diagnosis. St. Louis; C.V. Mosby Co.; 1966. p. 325-43. 34 35 Jerrold L. Informed consent in orthodontics. American Journal of Orthodontics and Dentofacial 36 Orthopedics 1988;93:251-8. 37 38 Johnson AL. Basic principles of orthodontia. Dental Cosmos 1923;65:503-518. 39 40 Langford SR, Sims MR. Upper molar root resorption because of distal movement. Report of a 41 case. American Journal of Orthodontics 1981;79:669-79. 42 43 Machen DE. Legal aspects of orthodontic practice: risk management concepts. Alternative 44 treatment plans. American Journal of Orthodontics and Dentofacial Orthopedics 1991;99:91-2. 45 46 Moyers RE. Standards of human occlusal development. Craniofacial growth series No. 5 Ann 47 Arbor, MI: Center for Human Growth and Development, University of Michigan; 1976. 48 49 Popovich F, Thompson GW. Craniofacial templates for orthodontic case analysis. American 50 Journal of Orthodontics 1977;71:406-20. 51

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1 Proffit WR. Contemporary orthodontics. 2nd ed. St. Louis: Mosby-Year Book; 1993. 2 3 Remington DN, Joondeph DR, Artun J, Riedel, RA, Chapko MK. Long-term evaluation of root 4 resorption occurring during orthodontic treatment. American Journal of Orthodontics and 5 Dentofacial Orthopedics 1989;96:43-6. 6 7 Rinchuse DJ, Rinchuse DJ, Sosovicka MF, Robison JM, Pendleton R. Orthodontic treatment of 8 patients using bisphosphonates: a report of 2 cases. American Journal of Orthodontics and 9 Dentofacial Orthopedics 2007;131:321-6. 10 11 Rizzoli R, Burlet N, Cahall D, Delmas PD, Eriksen EF, Felsenberg D, Grbic J, Jontell M, 12 Landesberg R, Laslop A, Wollenhaupt M, Papapoulos S, Sezer O, Sprafka M, Reginster JY. 13 Osteonecrosis of the jaw and bisphosphonate treatment for osteoporosis. Bone 2008;42:841-7. 14 15 Younis O, Hughes DO, Weber FN. Enamel decalcification in orthodontic treatment. American 16 Journal of Orthodontics 1979;75:678-81. 17 18 Zachrisson BU. Bonding in orthodontics. In: Graber TM, Vanarsdall RL. Orthodontics: current 19 principles and techniques. 2nd ed. St. Louis: Mosby; 1994. p. 542-626. 20 21 Post Treatment Evaluation and Outcomes Assessment 22 23 American Association of Orthodontists. Guidelines for quality assessment of orthodontic care. St. 24 Louis: American Association of Orthodontists; 1988. 25 26 Bader JD. Variation, treatment outcomes, and practice guidelines in dental practice. Journal of 27 Dental Education 1995;59:61-95. 28 29 Boyd RL. Two-year longitudinal study of a peroxide-fluoride rinse on decalcification in adolescent 30 orthodontic patients. Journal of Clinical Dentistry 1992;3:83-7. 31 32 Chateau M, Demoge PH. Evaluation of long term results of orthodontic therapy. International 33 Dental Journal 1961;11:29-46. 34 35 Goto S, Boyd RL, Nielsen L, Iizuka T. Long-term followup of orthodontic treatment of a patient with 36 maxillary protrusion, severe deep overbite and thumb-sucking. Angle Orthodontist 1994;64:7-12. 37 38 Graber TM. Postmortems in posttreatment adjustment. American Journal of Orthodontics 39 1966;52:331-52. 40 41 Korkhaus G (moderator). Posttreatment appraisal of orthodontic results. European Orthodontic 42 Society Transactions 1961;73-97. 43 44 Little RM, Riedel RA, Engst ED. Serial extraction of first premolars-postretention evaluation of 45 stability and relapse. Angle Orthodontist 1990;60:255-62. 46 47 Little RM, Riedel RA, Stein A. Mandibular arch length increase during the mixed dentition: 48 postretention evaluation of stability and relapse. American Journal of Orthodontics and Dentofacial 49 Orthopedics 1990;97:393-404. 50

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1 Little RM, Riedel RA. Postretention evaluation of stability and relapse-mandibular arches with 2 generalized spacing. American Journal of Orthodontics and Dentofacial Orthopedics 1989;95:37- 3 41. 4 5 McReynolds DC, Little RM. Mandibular second extraction-postretention evaluation of 6 stability and relapse. Angle Orthodontist 1991;61:133-44. 7 8 Pennsylvania Dental Association. Quality assessment guidelines. Harrisburg, PA: Pennsylvania 9 Dental Association; 1993. 10 11 Riedel RA, Little RM, Bui TD. Mandibular incisor extraction-postretention evaluation of stability and 12 relapse. Angle Orthodontist 1992;62:103-16. 13 14 Sadowsky C, Theisen TA, Sakols EI. Orthodontic treatment and temporomandibular joint sounds-a 15 longitudinal study. American Journal of Orthodontics and Dentofacial Orthopedics 1991;99:441-7. 16 17 Wade DB. Outcomes assessed by orthodontic programs. American Journal of Orthodontics and 18 Dentofacial Orthopedics 1994;106:109. 19 20 Retention 21 22 Behrents RG. A treatise on the continuum of growth in the aging craniofacial skeleton. [thesis] Ann 23 Arbor, MI: University of Michigan; 1984. 24 25 Kaplan H. The logic of modern retention procedures. American Journal of Orthodontics and 26 Dentofacial Orthopedics 1988;93:325-40. 27 28 Little RM, Riedel RA, Artun J. An evaluation of changes in mandibular anterior alignment from 10 29 to 20 years postretention. American Journal of Orthodontics and Dentofacial Orthopedics 30 1988;93:423-8. 31 32 Little RM, Wallen TR, Riedel RA. Stability and relapse of mandibular anterior alignment-first 33 premolar extraction cases treated by traditional edgewise orthodontics. American Journal of 34 Orthodontics 1981;80:349-65. 35 36 Lopez-Gavito G, Wallen TR, Little RM, Joondeph DR. Anterior open-bite malocclusion: a 37 longitudinal 10-year postretention evaluation of orthodontically treated patients. American Journal 38 of Orthodontics 1985;87:175-86. 39 40 Reitan K. Tissue rearrangement during retention of orthodontically rotated teeth. Angle 41 Orthodontist 1959;29:105-13. 42 43 Reitan K. Principles of retention and avoidance of posttreatment relapse. American Journal of 44 Orthodontics 1969;55:776-90. 45 46 Sondhi A, Cleall JF, BeGole EA. Dimensional changes in the dental arches of orthodontically 47 treated cases. American Journal of Orthodontics 1980;77:60-74. 48 49 Zachrisson BU. Adult retention: a new approach. In: Graber LW, Graber TM. Orthodontics, state of 50 the art, essence of the science. St. Louis: Mosby; 1986. p. 310-27. 51

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1 Record Keeping 2 3 American Association of Orthodontists. Orthodontics a patient education guide. St. Louis: 4 American Association of Orthodontists; 1991. 5 6 Eash C. Personnel file and recordkeeping. American Journal of Orthodontics and Dentofacial 7 Orthopedics 1994;105:610-1. 8 9 Jerrold L. Dental records and record keeping. American Journal of Orthodontics and Dentofacial 10 Orthopedics 1993;104:98-9. 11 12 Machen DE. Legal aspects of orthodontic practice: risk management concepts. Excellent 13 diagnostic informed consent practice and record keeping make a difference. American Journal of 14 Orthodontics and Dentofacial Orthopedics 1990;98:381-2. 15 16 Morin DR. The patient's records and the defense of dental malpractice claims. American Journal 17 of Orthodontics and Dentofacial Orthopedics 1992;102:569-70. 18 19 Transfer of Orthodontic Patients 20 21 American Association of Orthodontists. American Association of Orthodontists bylaws and 22 principles of ethics. St. Louis: American Association of Orthodontists; 1994. 23 24 American Association of Orthodontists. Guidelines for transfer of orthodontic cases. St. Louis: 25 American Association of Orthodontists; 1993.

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