Earn 1 CE credit This course was written for dentists, dental hygienists, and assistants.

Current Orthodontic Theory and Treatment A Peer-Reviewed Publication Written by Cathy Seckman, RDH

Abstract Learning Objectives: Author Profile The history of began in ancient times, At the conclusion of this educational Cathy Hester Seckman, RDH, is a pediatric hygienist as well as an leading us to assume that humankind has always seen activity participants will be able to: indexer, writer, and novelist. She has worked in 33 years, in- value in an attractive smile. Orthodontics was first 1. Name and describe common cluding eight years in a practice that includes orthodontic treatment. recognized as a specialty in the 19th century. In mod- orthodontic appliances. She presents CE courses on topics including pediatric management, ern dentistry, with evidence-based practice gaining 2. List the actions of and purposes for nutrition, pre-natal to pre-school care, communication, and ground, treatment options address as which different appliances are used. adolescent risk behaviors. She is a member of the American Dental well as problems in the transverse and vertical dimen- 3. Knowledgeably discuss invisible Hygienists Association and the Tri-County Ohio Dental Hygienists sions. Present-day practice includes the use of both orthodontics technology and use. Association. She can be reached at [email protected] . fixed and functional appliances. Dental hygienists 4. Customize oral hygiene recommen- with a working knowledge of orthodontic practice can dations for orthodontic appliances. Author Disclosure serve as valuable resources to patients and parents Cathy Hester Seckman has no potential conflicts of interest to from diagnosis to post-treatment questions. disclose.

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This educational activity was developed by PennWell’s Dental Group with no commercial support. Publication date: September 2012 Supplement to PennWell Publications This course was written for dentists, dental hygienists and assistants, from novice to skilled. Expiration date: August 2015 Educational Methods: This course is a self-instructional journal and web activity. Provider Disclosure: PennWell does not have a leadership position or a commercial interest in any products or services discussed or shared in this educational activity nor with the commercial supporter. No manufacturer or third party has had any input into the development of course content. Requirements for Successful Completion: To obtain 1 CE credit for this educational activity you must pay the required fee, review the material, complete the course evaluation and obtain a score of at least 70%. CE Planner Disclosure: Heather Hodges, CE Coordinator does not have a leadership or commercial interest with products or services discussed in this educational activity. Heather can be reached at [email protected] Educational Disclaimer: Completing a single continuing education course does not provide enough information PennWell designates this activity for 1 Continuing Educational Credit to result in the participant being an expert in the field related to the course topic. It is a combination of many educational courses and clinical experience that allows the participant to develop skills and expertise. Dental Board of California: Provider 4527, course registration number 01-4527-12070 Image Authenticity Statement: The images in this educational activity have not been altered. “This course meets the Dental Board of California’s requirements for 1 unit of continuing education.” Scientific Integrity Statement: Information shared in this CE course is developed from clinical research and The PennWell Corporation is designated as an Approved PACE Program Provider by the represents the most current information available from evidence based dentistry. Academy of General Dentistry. The formal continuing dental education programs of this Known Benefits and Limitations of the Data: The information presented in this educational activity is derived from program provider are accepted by the AGD for Fellowship, Mastership and membership the data and information contained in reference section. The research data is extensive and provides direct benefit to maintenance credit. Approval does not imply acceptance by a state or provincial board of the patient and improvements in oral health. dentistry or AGD endorsement. The current term of approval extends from (11/1/2011) to Registration: The cost of this CE course is $20.00 for 1 CE credit. (10/31/2015) Provider ID# 320452. Cancellation/Refund Policy: Any participant who is not 100% satisfied with this course can request a full refund by contacting PennWell in writing. Course Objectives: ously treated.”5 As orthodontic methodologies have advanced At the conclusion of this educational activity participants will with the availability of more socially acceptable hardware, ac- be able to: ceptance of treatment has improved. Braces had been seen as 1. Name and describe common orthodontic appliances. having a negative social impact, but the stigma of “tin grins” 2. List the actions of and purposes for which different appli- and “braces faces” has been alleviated in the popularity of ances are used. lingual braces, clear brackets, and invisible aligners. In fact, 3. Knowledgeably discuss invisible orthodontics technology braces are now seen as a desirable status symbol by some and use. adolescents. A few years ago, it was possible for teens in Thai- 4. Customize oral hygiene recommendations for orthodontic land to buy do-it-yourself kits of brackets and multicolored appliances. rubber bands and apply them as a fashion statement, but a consumer protection board has cracked down on the trend.6 Abstract In the absence of a handy kit, any fashion-conscious teen can The history of orthodontics began in ancient times, lead- build her own set of fake orthodontic hardware by using tin ing us to assume that humankind has always seen value in foil, opened paper clips, and metal earring backs.7 The focus an attractive smile. Orthodontics was first recognized as of this article is to present a history of the science, along with a specialty in the 19th century. In modern dentistry, with common diagnoses and treatment. evidence-based practice gaining ground, treatment options address malocclusions as well as problems in the transverse Figure 1: A stage tooth positioner and vertical dimensions. Present-day practice includes the use of both fixed and functional appliances. Dental hygienists with a working knowledge of orthodontic practice can serve as valuable resources to patients and parents from diagnosis to post-treatment questions.

Introduction One in three children, according to the British Orthodontic Society, needs orthodontic intervention.1 The physical and History of orthodontics psychological consequences of malocclusions can be dis- Evidence of what might have been orthodontic work – metal abling. Malocclusions have been shown to be a contributing bands wrapped around individual teeth – has been found in factor in the development of TMD; the likelihood of dental ancient mummies. Both Hippocrates and Aristotle wrote trauma; gingival recession; masticatory efficiency and ability; on ways to stabilize teeth with wires, and both Etruscans nutritional status; periodontal disease; and speech abnor- and Romans used appliances and ligature wire to maintain malities. Psychological consequences include damage to one’s space and move teeth.8 Within the last 250 years, though, the self-concept and self-confidence in both adolescence and science of orthodontics has advanced exponentially. Pierre adulthood.2 Adolescents with a history of orthodontics have Fauchard, in 1728, discussed ways to straighten teeth in his been shown to be less likely than those without such history book, The Surgeon Dentist. His bandeau, a horseshoe-shaped to report condition-specific impacts on their quality of life.3 implement, was intended to expand the arch. Another Since orthodontics as a science was developed in the 19th French dentist, Ettienne Bourdet, did further work with century, its focus has broadened from correction by force to the bandeau and is the first dentist on record to recommend correction by design. Jaw growth and expansion can be influ- extraction of premolars in cases of crowding. His book, The enced at an early age, avoiding the need for serial extractions. Dentist’s Art, was published in 1757. It was nearly a hundred Conventional banded orthodontics has been supplemented years later that the term “orthodontia” was first used by by the use of aligners and positioners, both removable and Joachim Lafoulon in 1841. Gum were first used to fixed. Orthodontic therapy can be mixed and matched to each straighten teeth in 1843, and bands cut from rubber tubing individual case, providing the best possible outcome for even in 1850. the most difficult cases. In the late 19th and early 20th centuries, several men are A study eliciting information on current trends indicated credited with bringing orthodontics into the modern age. that extraction rates have declined to 29.28% of cases.4 Al- Norman Kingsley, in his Treatise on Oral Deformities (1880), though adult orthodontics appears to be on the rise, a 2010 discussed orthodontic and cleft palate therapy.9 J.N. Farrar British study that attempted to discover the numbers of wrote A Treatise on the Irregularities of the Teeth and Their adults being treated came up short. The study found “no Corrections, and was the first to advocate moving teeth with comprehensive figures regarding the number of adults previ- mild force at timed intervals.10

2 www.ineedce.com The next important figure in the history of orthodontics Insurance reimbursement for orthodontics was first intro- was Edward H. Angle, DDS (1855-1930). Under Angle’s duced in the 1950s, and the 1970s saw a surge in the numbers leadership, orthodontics was recognized as a dental specialty, of orthodontic appliances available. Using acid etch bonding and he was the first to limit his practice to it. In 1899, his to attach orthodontic brackets became accepted clinical prac- article in Dental Cosmos described the classification of maloc- tice in the mid-1970s.12 Invisible – in clusion that we use today. His belief was that the best result other words, braces without all the ugly braces – has become of orthodontic treatment used a full complement of teeth, popular in the past decade. Today it’s possible for a patient with no extractions. to choose between clear-bracket braces such Damon Clear®;13 Two contemporaries of Angle, Calvin S. Case (1847- braces applied only to lingual surfaces, as with the 3M In- 1923) and Martin Dewey (1881-1933), disagreed with Angle cognito Appliance System®;14 and nearly invisible tray-style on the need for extractions, and the difference of opinion braces such as Clear Correct®15 and Invisalign®.16 caused serious contention among orthodontists for years. Some of the current issues concerning the field include Orthodontic appliances including vertical tubes and the treatment of the adult patient, increased use of orthognathic loop wire became standardized in the early 20th century. surgery, problems with TMD,11 and a continuing pressure for Herbert A. Pullen wrote on reintroduction of the maxillary evidence-based practice.17 suture opening in 1902; and Charles A. Hawley introduced his self-named appliance, still in use today, in 1908. Need for orthodontic treatment Malocclusions in modern society have recently been linked to our Figure 2: Upper Hawley with Adams clasps, a 2-2 labial bow, and a habitual masticatory forces. Von Cramon-Taubadel published a 2-2 lingual bar study in 2011 analyzing the relationship between mandibular shape variations and a subsistence society. Her results show that a decrease in masticatory stress causes the to grow and develop differently.18 In simpler terms, the processed and softer diet common in industrialized societies may lead to the increased prevalence of dental crowding and malocclusions. In planning a treatment strategy, multiple problems can be present. Orthodontists must consider not only , but tooth and arch size and transverse and vertical dimensions.

Malocclusion Determining the classic Angle classifications of malocclusion is the first step to diagnosing orthodontic issues. Class I is neutrocclusion, with the mesiobuccal cusp of the upper first molar aligned with the buccal groove of the mandibular first molar. Class II distocclusion occurs when upper first molars are anterior to the lower first molars. This is also known as overjet. Class II Division 1 includes protruded anterior teeth; Class II Division 2 presents with retroclined centrals and overlapping laterals. Class III mesiocclusion, or is diagnosed when the lower front teeth are more prominent than uppers. In any of these classes, there may also be crowd- ing, space issues, overeruption or undereruption.19

Transverse dimension In transverse dental relationships, problems can occur be- cause of narrowing of the maxillary arch or because of pos- Cephalometric radiography, tracing, and evaluation were terior crossbites. A too-narrow arch can occur congenitally developed by B. Holly Broadbent in 1931. Milo Hellman, in or because of breathing or finger sucking problems. With the 1930s, was the first to use research in anthropology to ad- crossbites, typically the upper posterior teeth are positioned vance the understanding of dentofacial growth and develop- lingually to the lower teeth. In rare cases, there is no occlusal ment. Serious research activity began in the 1940s, pioneered contact at all. To influence transverse dimension, orthodon- by Wilton M. Krogman, who developed criteria for child tists consider both conventional fixed appliance therapy and growth and development. growth modification with rapid maxillary expansion (RME).

www.ineedce.com 3 If skeletal malrelationships are 5 mm or greater, surgical cor- Common types of appliances rection may also be considered. RME (sometimes known as rapid Conventional fixed appliance therapy (RPE)) has been in use for 40 years and has the advantage This is the traditional bracket and band therapy with which of increasing transverse dimension quickly and easily in we are most familiar, and which is still most commonly used. children and adolescents, thus allowing a Class I relation- Each orthodontist will have specific preferences for angle, ship without extractions. It is mainly used to correct two torque, and style. discrepancies. In the case of a , applying lateral After teeth are banded and bracketed, resilient nickel force to the posterior maxillary molars causes separation titanium archwires are used to align and level the brackets. of the mid-palatal suture very quickly. For a tooth-size to Teeth are then rotated and roots torqued as necessary with a arch-size discrepancy, RME uses the same force to eliminate transpalatal arch. Elastomeric chains may be used to prevent crowding. The suture separation is temporary, and will fill in unwanted rotation. Interarch elastics are then used to correct with new osseous tissue. Transeptal fibers between the upper sagittal relationships. Maxillary anterior teeth are retracted if central incisors will also close the midline diastema caused by necessary with looped closing arches. The last step, called a the expansion.20 finishing sequence, seats the occlusion with archwires of high RME is normally used in mixed dentition, where it formability and triangular maxilla-to-mandible elastics. produces significant changes in measurements of sagittal, vertical, and transverse dimensions.21,22 Studies done in Class II functional appliances adults, however, have shown no evident or significant skel- etal changes after RME.23 This reinforces the advisability of Bionators beginning orthodontic treatment as early as possible. Removable Bionators are versatile appliances first used to treat mandibular retrusion in the 1960s. They are tooth-borne Vertical dimension appliances that produce a forward positioning of the lower Increasing vertical dimension is more problematic, with vary- jaw. As a Bionator repositions the lower jaw, it can simul- ing degrees of effectiveness. Types of vertical malocclusion taneously be designed either to open the bite by facilitating include an open bite and deep bite, which are dentoalveolar in posterior eruption; to close the bite in cases of dentoalveolar nature; and hyperdivergent or hypodivergent patterns of the open bite or skeletal open bite; or to maintain the bite when skeletal structure. existing vertical dimension is adequate.28 An open bite is defined as a malocclusion in which front or back teeth do not make contact with each other.24 Common Herbst causes of open bite are prolonged thumbsucking and airway A cantilever bite-jumping Herbst appliance is a complex obstruction that causes . Airway obstruction fixed metal appliance that is designed as a bilateral telescoping results in adenoid facies, which is the long, open-mouthed mechanism to reposition the lower jaw as the patient closes into look children develop with habitual mouth breathing.25 Be- occlusion. It can be combined with RME if necessary. The de- havior modification and conventional banded orthodontics vice was developed by Emil Herbst in the early 1900s, but came are used to correct an open bite, as well as extraoral traction into modern use after it was reintroduced by Hans Pancherz in with headgear, and removable appliances such as bionators 1979. A Herbst can be anchored either by bands or stainless and function regulators (described below). Posterior acrylic steel crowns on the first molars and premolars. Pivots soldered bite blocks can also be used to inhibit molar eruption, thereby to the buccal sides of the maxillary mounts secure tubes, into encouraging closure of the anterior open bite.20 which are inserted plungers attached to the lower first premo- A deep or closed bite occurs when the upper front teeth lars. As the patient opens and closes, the plungers ride up and overlap the bottom front teeth by an excessive amount.26 To down inside the tubes, guiding the jaw into correct occlusion.29 correct a deep bite, orthodontists open the bite by extrusion of posterior teeth, and by making changes in the masticatory Figure 3: Herbst appliance muscle balance. An anterior bite plate to encourage posterior extrusion can be used with extraoral traction or with fixed appliance treat- ment. Functionally, orthodontists may use a , twin blocks, or a Herbst appliance as well (described below). Orthognathic surgery is a common treatment to increase vertical dimension. The maxilla can be moved inferiorly, and can be advanced.27

4 www.ineedce.com MARA (mandibular anterior repositioning appliance) Schwarz appliance With these fixed appliances, “elbows” attached to maxillary A Schwarz appliance is an acrylic plate that includes embedded molars, and “arms” that protrude from mandibular molars, expansion screws. Typically, ball clasps extend through the in- force the patient to bite with the mandible in a forward posi- terproximals of posterior teeth for retention. The screw is turned tion. They can also be combined with RME.30 by the patient or parent weekly until desired expansion is gained. The appliance can be designed for the maxilla or mandible, and Figure 4: Molar distalizing appliance can include occlusal acrylic for a bite block effect if desired.33

Fixed expansion appliances (RMEs and RPEs) These appliances are used to improve transverse dimension on the maxilla or mandible. The bonded type encloses all of the posterior teeth in occlusal pads that control torque and vertical opening. The banded type is built on bands fitted to the first mo- lars and may include metal arms that extend across the palate or anteriorly to the incisors. Many have expansion screws in palatal Twin block acrylic that are adjusted daily by the patient or parent. Maxil- The original twin blocks were developed in the 1980s by Scottish lary bones are separated to the desired width, and the appliance orthodontist Dr. William Clark for Class II correction, and is bonded or wired in place until bone remodeling is complete.34 consist of upper and lower acrylic appliances. The upper usually includes expansion screws so the upper arch can be widened as Figure 6: Lower spring the lower arch moves forward to its new position. The upper and lower inclined occlusal planes, or wedges, interlock to hold the mandible forward and reposition the condyles.31

Class III functional appliances

Fränkel Function Regulator (FR-3) Used for Class III malocclusions, the FR-3 features vestibular acrylic shields and labial acrylic pads. The shields and pads counteract surrounding muscular forces that are restricting Figure 7: Upper expander already closed skeletal development. They stimulate maxillary alveolar devel- opment while restricting mandibular alveolar development.32

Removable expansion appliances A vulcanite appliance using an expansion screw was first described by Kingsley in 1877. Removable expansion appli- ances are considered to be “active plate” appliances rather than functional appliances because force is generated within the appliance itself by screws, wires, springs, or elastics that are adjusted by the patient or parent. They are typically used Figure 8: Lower removable expansion appliance prior to RME treatment to tip posterior teeth in a lateral di- rection by activating the expansion screw once a week.33

Figure 5: Rapid palatal expander with face crib hooks, low archwire tubes, and 7 wires

Dental hygiene considerations Orthodontic treatment includes increased caries risk, espe- cially with fixed appliances. Experts agree that communica-

www.ineedce.com 5 tion among patients, parents, orthodontists, and dentists References needs to improve to reduce the incidence of lesions.35 In one 1. http://www.bos.org.uk/orthodonticsandyou/orthodontics andthenhs/Did+you+know.htm study, metallic brackets in use for one month were found to 2. Zhang M, McGrath C, Hagg U. The impact of malocclusion and its be colonized by cariogenic microorganisms and periodontal treatment on quality of life: a literature review Int J Paed Dent 2006; 36 Volume 16, Issue 6, 381–387. pathogens. In another study, a negative effect on microbial 3. Bernabé E, Sheiham A, Tsakos G, Messias de Oliveira C.The flora was observed with long-term utilization of orthodontic impact of orthodontic treatment on the quality of life in adolescents: appliances. The study recommended patients be put on short a case-control study. Unidad de Investigación en Salud Pública 37 Dental, Departamento de Odontología Social, Universidad Peruana recare intervals during therapy. During treatment, there Cayetano Heredia, Perú. [email protected] are strategies that can be used to minimize caries and its 4. O’Connor BM. Contemporary trends in orthodontic practice: precursor, demineralization. When used to bond brackets, a national survey. Am J Orthod Dentofacial Orthop. 1993 Feb; 103(2):163-70. resin-modified glass ionomer cement and fluoride-releasing 5. Cedro MK, Moles DR, Hodges SJ. Adult orthodontics—who’s resin composite have been successfully used to inhibit de- doing what? J Orthod. 2010 Jun;37(2):107-17. 38 6. http://www.cbsnews.com/2100-202_162-1240516.html mineralization. During and after orthodontic treatment, 7. http://www.wikihow.com/Make-Fake-Braces-or-a-Fake-Retainer fluoride mouthrinses and at-home applications of fluoride 8. A brief history of braces http://www.archwired.com/ have been proven to reduce the occurrence and severity of HistoryofOrtho.htm) 9. Peck S. Dentist, artist, pioneer: Orthodontic innovator Norman 39 white spot lesion demineralization. Products containing ca- Kingsley and his Rembrandt portraits. J Am Dent Assoc. 2012 sein phosphopeptide-amorphous calcium phosphate (CPP- Apr;143(4):393-7. 10. http://inventors.about.com/od/dstartinventions/a/dentistry_4. ACP) have also been found to be useful in remineralization htm of white spot lesions.40 Adjuncts to oral care such as dental 11. Asbell MB. A brief history of orthodontics AJODO 1990; 98(3):206- floss, water flossers, and interproximal cleaners are helpful. 213. 12. Sadowsky PL. Clinical experience with the acid-etch technique in Non-floss users have been found to have significantly higher orthodontics. Am J Orthod. 1975 Dec; 68(6):645-54. means of plaque index, gingival index, pocket probing depth, 13. http://damonbraces.com/products/damon-clear/about.php 41 14. http://solutions.3m.com/wps/portal/3M/en_US/orthodontics/ and clinical attachment loss than floss users. Using dental Unitek/products/lingual/Incognito/ floss is admittedly problematic when archwires, springs, and 15. www.clearcorrect.com bands interfere. Floss threaders made by Butler GUM®, 16. www.invisalign.com ® ® ® ® 17. Law SV, Chudasama DN, Rinchuse DJ. Evidence-based DenTek , Crest Glide , Thornton , and Bridgeaid have orthodontics. Angle Orthod. 2010; 80 (5):952-956. been recommended for years. A new option is the Platypus 18. Von Cramon-Taubadel N. Global human mandibular variation ortho flosser, which is a U-shaped floss holder with one flat reflects differences in agricultural and hunter-gatherer subsistence strategies. Accepted by the Editorial Board October 19, 2011. side to slide beneath an archwire. 19. http://en.wikipedia.org/wiki/Malocclusion A 2008 study reported that plaque removal using a wa- 20. McNamera JA, Brudon WL. Orthodontics and Dentofacial Orthopedics. 1st ed. Ann Arbor MI: Needham Press; 2001: 97-108 ter flosser with a manual toothbrush was three to five times 21. Chung CH, Font B. Skeletal and dental changes in the sagittal, greater than patients who used a manual toothbrush alone.42 vertical, and transverse dimensions after rapid palatal expansion. The dozens of interdental cleaners on the market offer enough Am J Orthod Dentofacial Orthop. 2004 Nov; 126(5):569-75. 22. Garrett BJ, Caruso JM, Rungcharassaeng K, Farrage JR, Kim JS, variety to please any reluctant teen. Butler GUM Soft-Picks Taylor GD. Skeletal effects to the maxilla after rapid maxillary and Go-Betweens®, Proxabrushes®, Proxi-floss®, TePe®, and expansion assessed with cone-beam computed tomography. Am J Orthod Dentofacial Orthop. 2008 Jul; 134(1):8-9. others work well to clean interproximally. 23. Cephalometric study of slow maxillary expansion in adults. Am J Orthod Dentofacial Orthop. 2009 Sep; 136(3):348-54. Conclusion 24. http://www.mylifemysmile.org/glossary 25. http://radiopaedia.org/articles/adenoid-facies-2 A wide and deep array of fixed and removable appliances is 26. http://www.mylifemysmile.org/glossary in common use today in the field of orthodontics. The spe- 27. McNamera JA, Brudon WL. Orthodontics and Dentofacial Orthopedics. 1st ed. Ann Arbor MI: Needham Press; 2001: 111-141. cialty has evolved over hundreds of years of trial and error 28. McNamera JA, Brudon WL. Orthodontics and Dentofacial as researchers and practitioners strive to achieve the best Orthopedics. 1st ed. Ann Arbor MI: Needham Press; 2001: 319-322. outcomes in the most efficient manner. Research continues 29. McNamera JA, Brudon WL. Orthodontics and Dentofacial Orthopedics. 1st ed. Ann Arbor MI: Needham Press; 2001: 285-294. to refine the specialty, and evidence-based practice appears 30. Orthodontic Technologies http://www.orthodontictechnologies. to be increasing. A 2010 study reported on articles in the com/docs/products/productMara.pdf American Journal of Orthodontics and Dentofacial Orthope- 31. McNamera JA, Brudon WL. Orthodontics and Dentofacial Orthopedics. 1st ed. Ann Arbor MI: Needham Press; 2001: 243. dics. The percentage of original articles using statistics rose 32. McNamera JA, Brudon WL. Orthodontics and Dentofacial from 43.1% in 1975 to 92.9% in 2008. The percentage of Orthopedics. 1st ed. Ann Arbor MI: Needham Press; 2001: 265-267. 33. McNamera JA, Brudon WL. Orthodontics and Dentofacial articles using inferential statistical analyses rose from 74.2% Orthopedics. 1st ed. Ann Arbor MI: Needham Press; 2001: 233-237. in 1985 to 84.4% in 2008.17 34. Orthodontic Technologies http://www.orthodontictechnologies. The role of hygienists is as a resource for parents and pa- com/docs/products/productBandedRPE.pdf 35. Maxfield BJ, Hamdan AM, Tüfekçi E, Shroff B, Best AM, Lindauer tients in all phases of treatment, from initial assessments to SJ. Development of white spot lesions during orthodontic treatment: post-treatment questions. perceptions of patients, parents, orthodontists, and general dentists.

6 www.ineedce.com Am J Orthod Dentofacial Orthop. 2012 Mar; 141(3):337-44. Author profile 36. Andrucioli MC, Nelson-Filho P, Matsumoto MA, Saraiva MC, Feres. Molecular detection of in-vivo microbial contamination of metallic Cathy Hester Seckman, RDH, is a pediatric hygienist as well orthodontic brackets by checkerboard DNA-DNA hybridization. Am as an indexer, writer, and novelist. She has worked in dentistry J Orthod Dentofacial Orthop. 2012 Jan; 141(1):24-9. 33 years, including eight years in a practice that includes orth- 37. Topaloglu-Ak A, Ertugrul F, Eden E, Ates M, Bulut H. Effect of orthodontic appliances on oral microbiota—6 month follow-up. Clin odontic treatment. She presents CE courses on topics including Pediatr Dent. 2011; 35(4):433-6. pediatric management, nutrition, pre-natal to pre-school care, 38. Wilson RM, Donly KJ. Demineralization around orthodontic brackets bonded with resin-modified glass ionomer cement and communication, and adolescent risk behaviors. She is a member fluoride-releasing resin composite. Pediatr Dent. 2001 May-Jun; of the American Dental Hygienists Association and the Tri- 23(3):255-9. County Ohio Dental Hygienists Association. She can be reached 39. Benson PE, Shah AA, Millett DT, Dyer F, Parkin N, Vine RS. Fluorides, orthodontics and demineralization: a systematic review. J at [email protected] . Orthod. 2005; 32(2):102-14. 40. Llena C, Forner L, Baca P. Anticariogenicity of casein phosphopeptide- Acknowledgement amorphous calcium phosphate: a review of the literature. J Contemp Dent Pract. 2009 May 1; 10(3):1-9. The author would like to thank David Spokane, DMD, MS, for 41. Zanatta FB, Moreira CH, Rösing CK. Association between dental photographs and resources. floss use and gingival conditions in orthodontic patients. Am J Orthod Dentofacial Orthop. 2011 Dec; 140(6):812-21. 42. Sharma NC, Lyle DM, Qaqish JG, Galustians J, Schuller R. The Author Disclosure Effect of a Dental Water Jet with Orthodontic Tip on Plaque and Cathy Hester Seckman has no potential conflicts of interest to Bleeding in Adolescent Orthodontic Patients with Fixed Appliances. Am J Ortho Dentofacial Orthop 2008; 133(4):565-571. disclose.

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Questions

1. According to the British Orthodontic 6. Adenoid facies can be defined as: 11. Malocclusions have been shown to be a Society, the numbers of children who need a. A deep or closed bite contributing factor in: orthodontic intervention are: b. Facial appearance caused by mouthbreathing a. Efficiency and ability in mastication a. 2 in 10 c. Prognathism b. Nutritional status b. 1 in 20 d. Malocclusion c. Speech abnormalities d. All of the above c. 1 in 3 7. A deep bite is defined as: d. 2 in 20 a. Upper front teeth overlapping lowers by an excessive 12. The decline in extraction rates for current 2. Adolescents with a history of orthodontics amount orthodontic care is: are less likely to report: b. Upper front teeth overlapping lowers by a small amount a. 32.17 percent b. 47 percent a. Condition-specific impacts on their quality of life c. Upper front teeth behind lower front teeth c. 29.28 percent b. Fewer cavities d. Lower molars inside upper molars d. 16.80 percent c. Dissatisfaction with outcome 8. An appliance that uses tubes and plungers 13. The earliest book on orthodontics in d. b and c is a: modern times was: 3. The first dentist to limit his practice to a. Bionator a. The Dentist’s Art orthodontics was: b. Fränkel b. The Surgeon Dentist a. Calvin S. Case c. Twin block c. Treatise on the Irregularities of the Teeth and Their b. Joachim Lafoulon d. Herbst Corrections c. Charles A. Hawley 9. A Schwarz appliance includes this element: d. Orhtodontics and Dentofacial Orthopedics d. Edward H. Angle a. Ball clasps 14. Milo Hellman developed this important 4. Class II malocclusion is characterized by: b. Pivots orthodontic tool a. Distocclusion c. Elbows and arms a. Cephalometric radiography b. Neutrocclusion d. Vestibular acrylic shields b. c. Prognathism 10. Caries and demineralization during c. Vertical tubes d. Mesiocclusion and after orthodontic treatment may be d. Rapid palatal expanders 5. Rapid maxillary expansion is used to correct: minimized with: 15. An open bite can be caused by a. Crossbite a. Shorter recare intervals a. Airway obstruction b. Thumbsucking b. Interdental cleaners b. Too-narrow maxillary arch c. Tooth-size to arch-size discrepancy c. Glass ionomer cement c. Prolonged thumbsucking d. a and c d. All of the above d. a and c

www.ineedce.com 7 ANSWER SHEET Current Orthodontic Theory and Treatment

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Lic. Renewal Date: AGD Member ID: Requirements for successful completion of the course and to obtain dental continuing education credits: 1) Read the entire course. 2) Complete all information above. 3) Complete answer sheets in either pen or pencil. 4) Mark only one answer for each question. 5) A score of 70% on this test will earn you 1 CE credit. 6) Complete the Course Evaluation below. 7) Make check payable to PennWell Corp. For Questions Call 216.398.7822

Educational Objectives If not taking online, mail completed answer sheet to 1. Name and describe common orthodontic appliances. Academy of Dental Therapeutics and Stomatology, A Division of PennWell Corp. 2. List the actions of and purposes for which different appliances are used. P.O. Box 116, Chesterland, OH 44026 3. Knowledgeably discuss invisible orthodontics technology and use. or fax to: (440) 845-3447 4. Customize oral hygiene recommendations for orthodontic appliances.

For immediate results, Course Evaluation go to www.ineedce.com to take tests online. 1. Were the individual course objectives met? Objective #1: Yes No Objective #3: Yes No Answer sheets can be faxed with credit card payment to Objective #2: Yes No Objective #4: Yes No (440) 845-3447, (216) 398-7922, or (216) 255-6619. Please evaluate this course by responding to the following statements, using a scale of Excellent = 5 to Poor = 0. Payment of $20.00 is enclosed. (Checks and credit cards are accepted.) 2. To what extent were the course objectives accomplished overall? 5 4 3 2 1 0 If paying by credit card, please complete the 3. Please rate your personal mastery of the course objectives. 5 4 3 2 1 0 following: MC Visa AmEx Discover 4. How would you rate the objectives and educational methods? 5 4 3 2 1 0 Acct. Number: ______Exp. Date: ______5. How do you rate the author’s grasp of the topic? 5 4 3 2 1 0 Charges on your statement will show up as PennWell 6. Please rate the instructor’s effectiveness. 5 4 3 2 1 0 7. Was the overall administration of the course effective? 5 4 3 2 1 0 8. Please rate the usefulness and clinical applicability of this course. 5 4 3 2 1 0 9. Please rate the usefulness of the supplemental webliography. 5 4 3 2 1 0 10. Do you feel that the references were adequate? Yes No 11. Would you participate in a similar program on a different topic? Yes No 12. If any of the continuing education questions were unclear or ambiguous, please list them. ______13. Was there any subject matter you found confusing? Please describe. ______14. How long did it take you to complete this course? ______15. What additional continuing dental education topics would you like to see? ______AGD Code 371 ______PLEASE PHOTOCOPY ANSWER SHEET FOR ADDITIONAL PARTICIPANTS.

COURSE EVALUATION and PARTICIPANT FEEDBACK Provider Information RECORD KEEPING We encourage participant feedback pertaining to all courses. Please be sure to complete the survey included PennWell is an ADA CERP Recognized Provider. ADA CERP is a service of the American Dental Association PennWell maintains records of your successful completion of any exam for a minimum of six years. Please with the course. Please e-mail all questions to: [email protected]. to assist dental professionals in identifying quality providers of continuing dental education. ADA CERP contact our offices for a copy of your continuing education credits report. This report, which will list all does not approve or endorse individual courses or instructors, nor does it imply acceptance of credit hours credits earned to date, will be generated and mailed to you within five business days of receipt. INSTRUCTIONS by boards of dentistry. All questions should have only one answer. Grading of this examination is done manually. Participants will Completing a single continuing education course does not provide enough information to give the receive confirmation of passing by receipt of a verification form. Verification of Participation forms will be Concerns or complaints about a CE Provider may be directed to the provider or to ADA CERP at www.ada. participant the feeling that s/he is an expert in the field related to the course topic. It is a combination of mailed within two weeks after taking an examination. org/cotocerp/. many educational courses and clinical experience that allows the participant to develop skills and expertise. COURSE CREDITS/COST The PennWell Corporation is designated as an Approved PACE Program Provider by the Academy of General CANCELLATION/REFUND POLICY All participants scoring at least 70% on the examination will receive a verification form verifying 1 CE credit. Dentistry. The formal continuing dental education programs of this program provider are accepted by the Any participant who is not 100% satisfied with this course can request a full refund by contacting PennWell in writing. The formal continuing education program of this sponsor is accepted by the AGD for Fellowship/Mastership AGD for Fellowship, Mastership and membership maintenance credit. Approval does not imply acceptance credit. Please contact PennWell for current term of acceptance. Participants are urged to contact their state by a state or provincial board of dentistry or AGD endorsement. The current term of approval extends from Image Authenticity dental boards for continuing education requirements. PennWell is a California Provider. The California (11/1/2011) to (10/31/2015) Provider ID# 320452. The images provided and included in this course have not been altered. Provider number is 4527. The cost for courses ranges from $20.00 to $110.00. © 2014 by the Academy of Dental Therapeutics and Stomatology, a division of PennWell COTT214DE

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