Earn1 CE credit

This course was written for dentists, dental hygienists,

and assistants.

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

AbstractThe history of orthodontics began in ancient times, leading us to assume that humankind has always seen value in an attractive smile. Orthodontics was first recognized as a specialty in the 19th century. In mod-ern dentistry, with evidence-based practice gaining ground, treatment options address malocclusions as well as problems in the transverse and vertical dimen-sions. 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.

Learning Objectives:At the conclusion of this educational activity participants will be able to:1. Name and describe common

orthodontic appliances.2. List the actions of and purposes for

which different appliances are used.3. Knowledgeably discuss invisible

orthodontics technology and use.4. Customize oral hygiene recommen-

dations for orthodontic appliances.

Author ProfileCathy Hester Seckman, RDH, is a pediatric hygienist as well as an indexer, writer, and novelist. She has worked in dentistry 33 years, in-cluding eight years in a practice that includes orthodontic treatment. She presents CE courses on topics including pediatric management, nutrition, pre-natal to pre-school care, communication, and adolescent risk behaviors. She is a member of the American Dental Hygienists Association and the Tri-County Ohio Dental Hygienists Association. She can be reached at cathy@cathyseckman.com .

Author DisclosureCathy Hester Seckman has no potential conflicts of interest to disclose.

Publication date: September 2012 Expiration date: August 2015

This educational activity was developed by PennWell’s Dental Group with no commercial support.This course was written for dentists, dental hygienists and assistants, from novice to skilled. Educational Methods: This course is a self-instructional journal and web activity. Provider Disclosure: PennWell does not have a leadership position or a commercial interest in any products or services discussed or shared in this educational activity nor with the commercial supporter. No manufacturer or third party has had any input into the development of course content.Requirements for Successful Completion: To obtain 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 hhodges@pennwell.comEducational Disclaimer: Completing a single continuing education course does not provide enough information 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.Image Authenticity Statement: The images in this educational activity have not been altered.Scientific Integrity Statement: Information shared in this CE course is developed from clinical research and represents the most current information available from evidence based dentistry. Known Benefits and Limitations of the Data: The information presented in this educational activity is derived from the data and information contained in reference section. The research data is extensive and provides direct benefit to the patient and improvements in oral health. Registration: The cost of this CE course is $20.00 for 1 CE credit. Cancellation/Refund Policy: Any participant who is not 100% satisfied with this course can request a full refund by contacting PennWell in writing.

Supplement to PennWell Publications

PennWell designates this activity for 1 Continuing Educational Credit

Dental Board of California: Provider 4527, course registration number 01-4527-12070“This course meets the Dental Board of California’s requirements for 1 unit of continuing education.”

The PennWell Corporation is designated as an Approved PACE Program Provider by the Academy of General Dentistry. The formal continuing dental education programs of this program provider are accepted by the AGD for Fellowship, Mastership and membership maintenance credit. Approval does not imply acceptance by a state or provincial board of dentistry or AGD endorsement. The current term of approval extends from (11/1/2011) to (10/31/2015) Provider ID# 320452.

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Course Objectives:At the conclusion of this educational activity participants will be able to:1. Name and describe common orthodontic appliances.2. List the actions of and purposes for which different appli-

ances are used.3. Knowledgeably discuss invisible orthodontics technology

and use.4. Customize oral hygiene recommendations for orthodontic

appliances.

AbstractThe history of orthodontics began in ancient times, lead-ing us to assume that humankind has always seen value in an attractive smile. Orthodontics was first recognized as a specialty in the 19th century. In modern dentistry, with evidence-based practice gaining ground, treatment options address malocclusions as well as problems in the transverse 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.

IntroductionOne in three children, according to the British Orthodontic Society, needs orthodontic intervention.1 The physical and psychological consequences of malocclusions can be dis-abling. Malocclusions have been shown to be a contributing factor in the development of TMD; the likelihood of dental trauma; gingival recession; masticatory efficiency and ability; nutritional status; periodontal disease; and speech abnor-malities. Psychological consequences include damage to one’s self-concept and self-confidence in both adolescence and adulthood.2 Adolescents with a history of orthodontics have been shown to be less likely than those without such history to report condition-specific impacts on their quality of life.3

Since orthodontics as a science was developed in the 19th century, its focus has broadened from correction by force to correction by design. Jaw growth and expansion can be influ-enced at an early age, avoiding the need for serial extractions. Conventional banded orthodontics has been supplemented by the use of aligners and positioners, both removable and fixed. Orthodontic therapy can be mixed and matched to each individual case, providing the best possible outcome for even the most difficult cases.

A study eliciting information on current trends indicated that extraction rates have declined to 29.28% of cases.4 Al-though adult orthodontics appears to be on the rise, a 2010 British study that attempted to discover the numbers of adults being treated came up short. The study found “no comprehensive figures regarding the number of adults previ-

ously treated.”5 As orthodontic methodologies have advanced with the availability of more socially acceptable hardware, ac-ceptance of treatment has improved. Braces had been seen as having a negative social impact, but the stigma of “tin grins” and “braces faces” has been alleviated in the popularity of lingual braces, clear brackets, and invisible aligners. In fact, braces are now seen as a desirable status symbol by some adolescents. A few years ago, it was possible for teens in Thai-land to buy do-it-yourself kits of brackets and multicolored rubber bands and apply them as a fashion statement, but a consumer protection board has cracked down on the trend.6 In the absence of a handy kit, any fashion-conscious teen can build her own set of fake orthodontic hardware by using tin foil, opened paper clips, and metal earring backs.7 The focus of this article is to present a history of the science, along with common diagnoses and treatment.

Figure 1: A stage tooth positioner

History of orthodonticsEvidence of what might have been orthodontic work – metal bands wrapped around individual teeth – has been found in ancient mummies. Both Hippocrates and Aristotle wrote on ways to stabilize teeth with wires, and both Etruscans and Romans used appliances and ligature wire to maintain space and move teeth.8 Within the last 250 years, though, the science of orthodontics has advanced exponentially. Pierre Fauchard, in 1728, discussed ways to straighten teeth in his book, The Surgeon Dentist. His bandeau, a horseshoe-shaped implement, was intended to expand the arch. Another French dentist, Ettienne Bourdet, did further work with the bandeau and is the first dentist on record to recommend extraction of premolars in cases of crowding. His book, The Dentist’s Art, was published in 1757. It was nearly a hundred years later that the term “orthodontia” was first used by Joachim Lafoulon in 1841. Gum elastics were first used to straighten teeth in 1843, and bands cut from rubber tubing in 1850.

In the late 19th and early 20th centuries, several men are credited with bringing orthodontics into the modern age. Norman Kingsley, in his Treatise on Oral Deformities (1880), discussed orthodontic and cleft palate therapy.9 J.N. Farrar wrote A Treatise on the Irregularities of the Teeth and Their Corrections, and was the first to advocate moving teeth with mild force at timed intervals.10

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The next important figure in the history of orthodontics was Edward H. Angle, DDS (1855-1930). Under Angle’s leadership, orthodontics was recognized as a dental specialty, and he was the first to limit his practice to it. In 1899, his article in Dental Cosmos described the classification of maloc-clusion that we use today. His belief was that the best result of orthodontic treatment used a full complement of teeth, with no extractions.

Two contemporaries of Angle, Calvin S. Case (1847-1923) and Martin Dewey (1881-1933), disagreed with Angle on the need for extractions, and the difference of opinion caused serious contention among orthodontists for years.

Orthodontic appliances including vertical tubes and the loop wire became standardized in the early 20th century. Herbert A. Pullen wrote on reintroduction of the maxillary suture opening in 1902; and Charles A. Hawley introduced his self-named appliance, still in use today, in 1908.

Figure 2: Upper Hawley with Adams clasps, a 2-2 labial bow, and a 2-2 lingual bar

Cephalometric radiography, tracing, and evaluation were developed by B. Holly Broadbent in 1931. Milo Hellman, in the 1930s, was the first to use research in anthropology to ad-vance the understanding of dentofacial growth and develop-ment. Serious research activity began in the 1940s, pioneered by Wilton M. Krogman, who developed criteria for child growth and development.

Insurance reimbursement for orthodontics was first intro-duced in the 1950s, and the 1970s saw a surge in the numbers of orthodontic appliances available. Using acid etch bonding to attach orthodontic brackets became accepted clinical prac-tice in the mid-1970s.12 Invisible orthodontic technology – in other words, braces without all the ugly braces – has become popular in the past decade. Today it’s possible for a patient to choose between clear-bracket braces such Damon Clear®;13 braces applied only to lingual surfaces, as with the 3M In-cognito Appliance System®;14 and nearly invisible tray-style braces such as Clear Correct®15 and Invisalign®.16

Some of the current issues concerning the field include treatment of the adult patient, increased use of orthognathic surgery, problems with TMD,11 and a continuing pressure for evidence-based practice.17

Need for orthodontic treatmentMalocclusions in modern society have recently been linked to our habitual masticatory forces. Von Cramon-Taubadel published a 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 mandible 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 malocclusion, but tooth and arch size and transverse and vertical dimensions.

MalocclusionDetermining 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 prognathism 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 dimensionIn transverse dental relationships, problems can occur be-cause of narrowing of the maxillary arch or because of pos-terior crossbites. A too-narrow arch can occur congenitally or because of breathing or finger sucking problems. With crossbites, typically the upper posterior teeth are positioned lingually to the lower teeth. In rare cases, there is no occlusal contact at all. To influence transverse dimension, orthodon-tists consider both conventional fixed appliance therapy and growth modification with rapid maxillary expansion (RME).

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If skeletal malrelationships are 5 mm or greater, surgical cor-rection may also be considered.

RME (sometimes known as rapid palatal expansion (RPE)) has been in use for 40 years and has the advantage of increasing transverse dimension quickly and easily in children and adolescents, thus allowing a Class I relation-ship without extractions. It is mainly used to correct two discrepancies. In the case of a crossbite, applying lateral force to the posterior maxillary molars causes separation of the mid-palatal suture very quickly. For a tooth-size to arch-size discrepancy, RME uses the same force to eliminate crowding. The suture separation is temporary, and will fill in with new osseous tissue. Transeptal fibers between the upper central incisors will also close the midline diastema caused by the expansion.20

RME is normally used in mixed dentition, where it produces significant changes in measurements of sagittal, vertical, and transverse dimensions.21,22 Studies done in adults, however, have shown no evident or significant skel-etal changes after RME.23 This reinforces the advisability of beginning orthodontic treatment as early as possible.

Vertical dimensionIncreasing vertical dimension is more problematic, with vary-ing degrees of effectiveness. Types of vertical malocclusion include an open bite and deep bite, which are dentoalveolar in nature; and hyperdivergent or hypodivergent patterns of the skeletal structure.

An open bite is defined as a malocclusion in which front or back teeth do not make contact with each other.24 Common causes of open bite are prolonged thumbsucking and airway obstruction that causes mouth breathing. Airway obstruction results in adenoid facies, which is the long, open-mouthed look children develop with habitual mouth breathing.25 Be-havior modification and conventional banded orthodontics are used to correct an open bite, as well as extraoral traction with headgear, and removable appliances such as bionators and function regulators (described below). Posterior acrylic bite blocks can also be used to inhibit molar eruption, thereby encouraging closure of the anterior open bite.20

A deep or closed bite occurs when the upper front teeth overlap the bottom front teeth by an excessive amount.26 To correct a deep bite, orthodontists open the bite by extrusion of posterior teeth, and by making changes in the masticatory muscle balance.

An anterior bite plate to encourage posterior extrusion can be used with extraoral traction or with fixed appliance treatment. Functionally, orthodontists may use a Frankel ap-pliance, 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 mandibles can be advanced.27

Common types of appliances

Conventional fixed appliance therapyThis is the traditional bracket and band therapy with which we are most familiar, and which is still most commonly used. Each orthodontist will have specific preferences for angle, torque, and style.

After teeth are banded and bracketed, resilient nickel titanium archwires are used to align and level the brackets. Teeth are then rotated and roots torqued as necessary with a transpalatal arch. Elastomeric chains may be used to prevent unwanted rotation. Interarch elastics are then used to correct sagittal relationships. Maxillary anterior teeth are retracted if necessary with looped closing arches. The last step, called a finishing sequence, seats the occlusion with archwires of high formability and triangular maxilla-to-mandible elastics.

Class II functional appliances

BionatorsRemovable Bionators are versatile appliances first used to treat mandibular retrusion in the 1960s. They are tooth-borne appliances that produce a forward positioning of the lower jaw. As a Bionator repositions the lower jaw, it can simul-taneously be designed either to open the bite by facilitating posterior eruption; to close the bite in cases of dentoalveolar open bite or skeletal open bite; or to maintain the bite when existing vertical dimension is adequate.28

HerbstA cantilever bite-jumping Herbst appliance is a complex fixed metal appliance that is designed as a bilateral telescoping mechanism to reposition the lower jaw as the patient closes into occlusion. It can be combined with RME if necessary. The de-vice was developed by Emil Herbst in the early 1900s, but came into modern use after it was reintroduced by Hans Pancherz in 1979. A Herbst can be anchored either by bands or stainless steel crowns on the first molars and premolars. Pivots soldered to the buccal sides of the maxillary mounts secure tubes, into which are inserted plungers attached to the lower first premo-lars. As the patient opens and closes, the plungers ride up and down inside the tubes, guiding the jaw into correct occlusion.29

Figure 3: Herbst appliance

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MARA (mandibular anterior repositioning appliance)With these fixed appliances, “elbows” attached to maxillary molars, and “arms” that protrude from mandibular molars, force the patient to bite with the mandible in a forward posi-tion. They can also be combined with RME.30

Figure 4: Molar distalizing appliance

Twin blockThe original twin blocks were developed in the 1980s by Scottish orthodontist Dr. William Clark for Class II correction, and consist of upper and lower acrylic appliances. The upper usually includes expansion screws so the upper arch can be widened as 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 skeletal development. They stimulate maxillary alveolar devel-opment while restricting mandibular alveolar development.32

Removable expansion appliancesA 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 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

Schwarz applianceA Schwarz appliance is an acrylic plate that includes embedded expansion screws. Typically, ball clasps extend through the in-terproximals of posterior teeth for retention. The screw is turned by the patient or parent weekly until desired expansion is gained. The appliance can be designed for the maxilla or mandible, and 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 acrylic that are adjusted daily by the patient or parent. Maxil-lary bones are separated to the desired width, and the appliance is bonded or wired in place until bone remodeling is complete.34

Figure 6: Lower spring retainer

Figure 7: Upper expander already closed

Figure 8: Lower removable expansion appliance

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

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tion among patients, parents, orthodontists, and dentists needs to improve to reduce the incidence of lesions.35 In one study, metallic brackets in use for one month were found to be colonized by cariogenic microorganisms and periodontal pathogens.36 In another study, a negative effect on microbial flora was observed with long-term utilization of orthodontic appliances. The study recommended patients be put on short recare intervals during therapy.37 During treatment, there are strategies that can be used to minimize caries and its precursor, demineralization. When used to bond brackets, resin-modified glass ionomer cement and fluoride-releasing resin composite have been successfully used to inhibit de-mineralization.38 During and after orthodontic treatment, fluoride mouthrinses and at-home applications of fluoride have been proven to reduce the occurrence and severity of white spot lesion demineralization.39 Products containing ca-sein phosphopeptide-amorphous calcium phosphate (CPP-ACP) have also been found to be useful in remineralization of white spot lesions.40 Adjuncts to oral care such as dental floss, water flossers, and interproximal cleaners are helpful. Non-floss users have been found to have significantly higher means of plaque index, gingival index, pocket probing depth, and clinical attachment loss than floss users.41 Using dental floss is admittedly problematic when archwires, springs, and bands interfere. Floss threaders made by Butler GUM®, DenTek®, Crest Glide®, Thornton®, and Bridgeaid® have been recommended for years. A new option is the Platypus ortho flosser, which is a U-shaped floss holder with one flat side to slide beneath an archwire.

A 2008 study reported that plaque removal using a wa-ter flosser with a manual toothbrush was three to five times greater than patients who used a manual toothbrush alone.42 The dozens of interdental cleaners on the market offer enough variety to please any reluctant teen. Butler GUM Soft-Picks and Go-Betweens®, Proxabrushes®, Proxi-floss®, TePe®, and others work well to clean interproximally.

ConclusionA wide and deep array of fixed and removable appliances is in common use today in the field of orthodontics. The spe-cialty has evolved over hundreds of years of trial and error as researchers and practitioners strive to achieve the best outcomes in the most efficient manner. Research continues to refine the specialty, and evidence-based practice appears to be increasing. A 2010 study reported on articles in the American Journal of Orthodontics and Dentofacial Orthope-dics. The percentage of original articles using statistics rose from 43.1% in 1975 to 92.9% in 2008. The percentage of articles using inferential statistical analyses rose from 74.2% in 1985 to 84.4% in 2008.17

The role of hygienists is as a resource for parents and pa-tients in all phases of treatment, from initial assessments to post-treatment questions.

References1. http://www.bos.org.uk/orthodonticsandyou/orthodontics

andthenhs/Did+you+know.htm2. Zhang M, McGrath C, Hagg U. The impact of malocclusion and its

treatment on quality of life: a literature review Int J Paed Dent 2006; Volume 16, Issue 6, 381–387.

3. Bernabé E, Sheiham A, Tsakos G, Messias de Oliveira C.The impact of orthodontic treatment on the quality of life in adolescents: a case-control study. Unidad de Investigación en Salud Pública Dental, Departamento de Odontología Social, Universidad Peruana Cayetano Heredia, Perú. e.bernabe@ucl.ac.uk

4. O’Connor BM. Contemporary trends in orthodontic practice: a national survey. Am J Orthod Dentofacial Orthop. 1993 Feb; 103(2):163-70.

5. Cedro MK, Moles DR, Hodges SJ. Adult orthodontics—who’s doing what? J Orthod. 2010 Jun;37(2):107-17.

6. http://www.cbsnews.com/2100-202_162-1240516.html 7. http://www.wikihow.com/Make-Fake-Braces-or-a-Fake-Retainer8. A brief history of braces http://www.archwired.com/

HistoryofOrtho.htm) 9. Peck S. Dentist, artist, pioneer: Orthodontic innovator Norman

Kingsley and his Rembrandt portraits. J Am Dent Assoc. 2012 Apr;143(4):393-7.

10. http://inventors.about.com/od/dstartinventions/a/dentistry_4.htm

11. Asbell MB. A brief history of orthodontics AJODO 1990; 98(3):206-213.

12. Sadowsky PL. Clinical experience with the acid-etch technique in orthodontics. Am J Orthod. 1975 Dec; 68(6):645-54.

13. http://damonbraces.com/products/damon-clear/about.php14. http://solutions.3m.com/wps/portal/3M/en_US/orthodontics/

Unitek/products/lingual/Incognito/15. www.clearcorrect.com16. www.invisalign.com17. Law SV, Chudasama DN, Rinchuse DJ. Evidence-based

orthodontics. Angle Orthod. 2010; 80 (5):952-956.18. Von Cramon-Taubadel N. Global human mandibular variation

reflects differences in agricultural and hunter-gatherer subsistence strategies. Accepted by the Editorial Board October 19, 2011.

19. http://en.wikipedia.org/wiki/Malocclusion20. McNamera JA, Brudon WL. Orthodontics and Dentofacial

Orthopedics. 1st ed. Ann Arbor MI: Needham Press; 2001: 97-10821. Chung CH, Font B. Skeletal and dental changes in the sagittal,

vertical, and transverse dimensions after rapid palatal expansion. Am J Orthod Dentofacial Orthop. 2004 Nov; 126(5):569-75.

22. Garrett BJ, Caruso JM, Rungcharassaeng K, Farrage JR, Kim JS, Taylor GD. Skeletal effects to the maxilla after rapid maxillary expansion assessed with cone-beam computed tomography. Am J Orthod Dentofacial Orthop. 2008 Jul; 134(1):8-9.

23. Cephalometric study of slow maxillary expansion in adults. Am J Orthod Dentofacial Orthop. 2009 Sep; 136(3):348-54.

24. http://www.mylifemysmile.org/glossary 25. http://radiopaedia.org/articles/adenoid-facies-2 26. http://www.mylifemysmile.org/glossary27. McNamera JA, Brudon WL. Orthodontics and Dentofacial

Orthopedics. 1st ed. Ann Arbor MI: Needham Press; 2001: 111-141.28. McNamera JA, Brudon WL. Orthodontics and Dentofacial

Orthopedics. 1st ed. Ann Arbor MI: Needham Press; 2001: 319-322.29. McNamera JA, Brudon WL. Orthodontics and Dentofacial

Orthopedics. 1st ed. Ann Arbor MI: Needham Press; 2001: 285-294.30. Orthodontic Technologies http://www.orthodontictechnologies.

com/docs/products/productMara.pdf31. McNamera JA, Brudon WL. Orthodontics and Dentofacial

Orthopedics. 1st ed. Ann Arbor MI: Needham Press; 2001: 243.32. McNamera JA, Brudon WL. Orthodontics and Dentofacial

Orthopedics. 1st ed. Ann Arbor MI: Needham Press; 2001: 265-267.33. McNamera JA, Brudon WL. Orthodontics and Dentofacial

Orthopedics. 1st ed. Ann Arbor MI: Needham Press; 2001: 233-237.34. Orthodontic Technologies http://www.orthodontictechnologies.

com/docs/products/productBandedRPE.pdf35. Maxfield BJ, Hamdan AM, Tüfekçi E, Shroff B, Best AM, Lindauer

SJ. Development of white spot lesions during orthodontic treatment: perceptions of patients, parents, orthodontists, and general dentists.

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Questions

Online CompletionUse this page to review the questions and answers. Return to www.ineedce.com and sign in. If you have not previously purchased the program select it from the “Online Courses” listing and complete the online purchase. Once purchased the exam will be added to your Archives page where a Take Exam link will be provided. Click on the “Take Exam” link, complete all the program questions and submit your answers. An immediate grade report will be provided and upon receiving a passing grade your “Verification Form” will be provided immediately for viewing and/or printing. Verification Forms can be viewed and/or printed anytime in the future by returning to the site, sign in and return to your Archives Page.

1. According to the British Orthodontic Society, the numbers of children who need orthodontic intervention are:a. 2 in 10b. 1 in 20c. 1 in 3d. 2 in 20

2. Adolescents with a history of orthodontics are less likely to report:a. Condition-specific impacts on their quality of lifeb. Fewer cavitiesc. Dissatisfaction with outcomed. b and c

3. The first dentist to limit his practice to orthodontics was: a. Calvin S. Caseb. Joachim Lafoulonc. Charles A. Hawleyd. Edward H. Angle

4. Class II malocclusion is characterized by:a. Distocclusionb. Neutrocclusionc. Prognathismd. Mesiocclusion

5. Rapid maxillary expansion is used to correct:a. Crossbiteb. Thumbsuckingc. Tooth-size to arch-size discrepancyd. a and c

6. Adenoid facies can be defined as:a. A deep or closed biteb. Facial appearance caused by mouthbreathingc. Prognathismd. Malocclusion

7. A deep bite is defined as:a. Upper front teeth overlapping lowers by an excessive

amountb. Upper front teeth overlapping lowers by a small amountc. Upper front teeth behind lower front teethd. Lower molars inside upper molars

8. An appliance that uses tubes and plungers is a:a. Bionatorb. Fränkelc. Twin blockd. Herbst

9. A Schwarz appliance includes this element:a. Ball claspsb. Pivotsc. Elbows and armsd. Vestibular acrylic shields

10. Caries and demineralization during and after orthodontic treatment may be minimized with:a. Shorter recare intervalsb. Interdental cleanersc. Glass ionomer cementd. All of the above

11. Malocclusions have been shown to be a contributing factor in: a. Efficiency and ability in masticationb. Nutritional statusc. Speech abnormalitiesd. All of the above

12. The decline in extraction rates for current orthodontic care is:a. 32.17 percentb. 47 percentc. 29.28 percentd. 16.80 percent

13. The earliest book on orthodontics in modern times was:a. The Dentist’s Artb. The Surgeon Dentistc. Treatise on the Irregularities of the Teeth and Their

Correctionsd. Orhtodontics and Dentofacial Orthopedics

14. Milo Hellman developed this important orthodontic toola. Cephalometric radiographyb. Clear alignersc. Vertical tubesd. Rapid palatal expanders

15. An open bite can be caused bya. Airway obstructionb. Too-narrow maxillary archc. Prolonged thumbsuckingd. a and c

Am J Orthod Dentofacial Orthop. 2012 Mar; 141(3):337-44. 36. Andrucioli MC, Nelson-Filho P, Matsumoto MA, Saraiva MC, Feres.

Molecular detection of in-vivo microbial contamination of metallic orthodontic brackets by checkerboard DNA-DNA hybridization. Am J Orthod Dentofacial Orthop. 2012 Jan; 141(1):24-9.

37. Topaloglu-Ak A, Ertugrul F, Eden E, Ates M, Bulut H. Effect of orthodontic appliances on oral microbiota—6 month follow-up. Clin Pediatr Dent. 2011; 35(4):433-6.

38. Wilson RM, Donly KJ. Demineralization around orthodontic brackets bonded with resin-modified glass ionomer cement and fluoride-releasing resin composite. Pediatr Dent. 2001 May-Jun; 23(3):255-9.

39. Benson PE, Shah AA, Millett DT, Dyer F, Parkin N, Vine RS. Fluorides, orthodontics and demineralization: a systematic review. J Orthod. 2005; 32(2):102-14.

40. Llena C, Forner L, Baca P. Anticariogenicity of casein phosphopeptide-amorphous calcium phosphate: a review of the literature. J Contemp Dent Pract. 2009 May 1; 10(3):1-9.

41. Zanatta FB, Moreira CH, Rösing CK. Association between dental 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 Effect of a Dental Water Jet with Orthodontic Tip on Plaque and Bleeding in Adolescent Orthodontic Patients with Fixed Appliances. Am J Ortho Dentofacial Orthop 2008; 133(4):565-571.

Author profileCathy Hester Seckman, RDH, is a pediatric hygienist as well as an indexer, writer, and novelist. She has worked in dentistry 33 years, including eight years in a practice that includes orth-odontic treatment. She presents CE courses on topics including pediatric management, nutrition, pre-natal to pre-school care, communication, and adolescent risk behaviors. She is a member of the American Dental Hygienists Association and the Tri-County Ohio Dental Hygienists Association. She can be reached at cathy@cathyseckman.com .

AcknowledgementThe author would like to thank David Spokane, DMD, MS, for photographs and resources.

Author DisclosureCathy Hester Seckman has no potential conflicts of interest to disclose.

Educational Objectives1. Name and describe common orthodontic appliances.

2. List the actions of and purposes for which different appliances are used.

3. Knowledgeably discuss invisible orthodontics technology and use.

4. Customize oral hygiene recommendations for orthodontic appliances.

Course Evaluation1. Were the individual course objectives met? Objective #1: Yes No Objective #3: Yes No

Objective #2: Yes No Objective #4: Yes No

Please evaluate this course by responding to the following statements, using a scale of Excellent = 5 to Poor = 0.

2. To what extent were the course objectives accomplished overall? 5 4 3 2 1 0

3. Please rate your personal mastery of the course objectives. 5 4 3 2 1 0

4. How would you rate the objectives and educational methods? 5 4 3 2 1 0

5. How do you rate the author’s grasp of the topic? 5 4 3 2 1 0

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? ___________________________________________________________________ ___________________________________________________________________

ANSWER SHEET

Current Orthodontic Theory and Treatment

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requiremeNTS for SucceSSful compleTioN of The courSe aNd To obTaiN deNTal coNTiNuiNG educaTioN crediTS: 1) read The eNTire courSe. 2) compleTe all iNformaTioN above. 3) compleTe aNSwer SheeTS iN eiTher peN or peNcil. 4) mark oNly oNe aNSwer for each queSTioN. 5) a Score of 70% oN ThiS TeST will earN you 1 ce crediT. 6) compleTe The courSe evaluaTioN below. 7) make check payable To peNNwell corp. For Questions Call 216.398.7822

AGD Code 371

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PLEASE PHOTOCOPY ANSWER SHEET FOR ADDITIONAL PARTICIPANTS.COURSE EVALUATION and PARTICIPANT FEEDBACK

We encourage participant feedback pertaining to all courses. Please be sure to complete the survey included with the course. Please e-mail all questions to: hhodges@pennwell.com.

INSTRUCTIONSAll questions should have only one answer. Grading of this examination is done manually. Participants will receive confirmation of passing by receipt of a verification form. Verification of Participation forms will be mailed within two weeks after taking an examination.

COURSE CREDITS/COSTAll participants scoring at least 70% on the examination will receive a verification form verifying 1 CE credit. The formal continuing education program of this sponsor is accepted by the AGD for Fellowship/Mastership credit. Please contact PennWell for current term of acceptance. Participants are urged to contact their state dental boards for continuing education requirements. PennWell is a California Provider. The California Provider number is 4527. The cost for courses ranges from $20.00 to $110.00.

PROVIDER INFORMATIONPennWell is an ADA CERP Recognized Provider. ADA CERP is a service of the American Dental Association to assist dental professionals in identifying quality providers of continuing dental education. ADA CERP does not approve or endorse individual courses or instructors, nor does it imply acceptance of credit hours by boards of dentistry.

Concerns or complaints about a CE Provider may be directed to the provider or to ADA CERP at www.ada.org/cotocerp/.

The PennWell Corporation is designated as an Approved PACE Program Provider by the Academy of General Dentistry. The formal continuing dental education programs of this program provider are accepted by the AGD for Fellowship, Mastership and membership maintenance credit. Approval does not imply acceptance by a state or provincial board of dentistry or AGD endorsement. The current term of approval extends from (11/1/2011) to (10/31/2015) Provider ID# 320452.

RECORD KEEPINGPennWell maintains records of your successful completion of any exam for a minimum of six years. Please contact our offices for a copy of your continuing education credits report. This report, which will list all credits earned to date, will be generated and mailed to you within five business days of receipt.

Completing a single continuing education course does not provide enough information to give the participant the feeling that s/he is 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.

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IMAGE AUTHENTICITYThe images provided and included in this course have not been altered.

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