THE COLLEGE E-ZINE THE COLLEGE OF DIPLOMATES OF THE AMERICAN BOARD OF ORTHODONTICS
“Keeping Our Members Connected”
39 ANNUAL th
Where: Squaw Creek Resort, Squaw Valley, CA When: July 7-11, 2017
TABLE OF CONTENTS INTRODUCTION DR. MICHAEL GUESS............................................................................................................... 3 PRESIDENT’S MESSAGE DR. PAUL MILLER.....................................................................................................................4 A BIT OF HISTORY ABOUT LAKE TAHOE.............................................................................. 7 PLACES TO TO DINE IN NORTH LAKE TAHOE....................................................................11 39TH ANNUAL MEETING SCIENTIFIC SPEAKER LIST.......................................................... 12 MEETING SCHEDULE.............................................................................................................13 HIGH VALUE SCENARIOS FOR CBCT IMAGING IN ORTHODONICS DR. DAVID HATCHER & DR. SHIKHA RATHI........................................................................17 AMERICAN BOARD OF ORTHODONTICS REPORT DR. CHUN-HSI CHUNG........................................................................................................ 36 NEW ABO PRESIDENT DR. CHUN-HSI CHUNG........................................................................................................ 37 STUDENT MEMBERSHIP APPLICATION.............................................................................. 38 FUTURE MEETINGS............................................................................................................... 39 EVALUATING PROFESSIONAL ADVICE: 11 QUESTIONS TO ANSWER BEFORE YOU COMMIT RICH ARZAGA, CFP, CCIM.....................................................................................................40
PREVIOUS E-ZINES AVAILABLE HERE: Spring 2014 36th Annual meeting - QR Code Review https://issuu.com/cdabo/docs/e-zine_summer_meeting_-_19_march_we Fall 2015 37th Annual Meeting https://issuu.com/cdabo/docs/e-zine_s-f_issue_ii Summer 2015 37th Annual Meeting https://issuu.com/cdabo/docs/e-zine_summer_meeting_may_29-_2015_ Fall 2016 38th Annual Meeting https://issuu.com/cdabo/docs/e-zine_38_th_summer_meeting_okt_27_
Summer 2016 38th Annual Meeting https://issuu.com/cdabo/docs/cdabo_e-zine_38th_summer_meeting_20 Fall 2016 39th Annual Meeting https://issuu.com/cdabo/docs/cdabo_fall_2016_lake_tahoe Disclaimer: “The views and opinions expressed in this ezine are those of the author and not necessarily reflect the views of the College of Diplomates, Council or its members.” ©CDABO 2017
Sobler is already planning next summer’s meeting at Disney in Orlando. And in 2019, Dr. Eric Dellinger has his committees working for his meeting scheduled for Nashville.
INTRODUCTION Dr. Michael Guess Hello everyone! Welcome to the spring edition of the College E-zine. I am delighted to present our latest issue to update and invite our members to participate at the 39th annual summer meeting scheduled from July 7-11, 2017 at the Resort in Squaw Creek, near Lake Tahoe, California. I believe that you will find this year’s program topic, “Controversies: The Stability Of The End Result” both informative and stimulating. As is our tradition, Dr. Paul Miller and his meeting team have organized an outstanding group of speakers that will keep you on the edge of your seat until about noon each day. In the afternoon there are ample opportunites to explore the area with family and friends and informal interactions with colleagues. These informal interactions have long contributed to the appeal of the College’s annual summer as an opportunity not only to attend presentations of cutting-edge research and information, but also to “rub elbows” with like minded orthodontists and friends.
Congratulations to Dr. Chun-Hsi Chung on recent appointment as the new President of the ABO. We wish him a successful and productive year. And Finally, I’d like to offer my congratulations to Dr. Paul Miller. Under his stewardship this past year has been very smooth and productive for the College. We are looking forward to rekindling our relationships with long-time members and first time attendees. Joining the annual meeting with the College can be a life changing experience. Don’t put it off another year! This issue is rather long due but has several ‘pearls’ within it’s covers. Make sure to review the wonderful article contributed by Dr. David Hatcher and Dr. Shikha Rathi entitled, “High Value Scenarios For CBCT Imaging In Orthodontics.” The entire Council looks forward to seeing you at Squaw Creek Resort!
I am very grateful to the College Council for allowing me to develop the e-zine for our members. Dr. Paul Miller will yield the President’s gavel this summer for Dr. Terry Sobler. Dr.
PS – Past issues of the College E-zine can be found on www.issuu.com under CDABO.
Dr. Michael B. Guess
PRESIDENT’S MESSAGE Dr. Paul E. Miller
t has been a pleasure and privilege to serve as the President of the College of Diplomates of the American Board of Orthodontics this past year. The experience has been humbling and I’ve enjoyed this opportunity.
The College is an organization that orthodontists aspire to join and participate in and other orthodontic organizations want to emulate. The core value of the College is to promote and support the pursuit of enhanced quality of care through the process of ABO certification,
recertification, and continuing education. My goals have been to continue this process. During this past year, The College has continued our Annual Awards Luncheon for the ABO, Prep Course at the AAO, Resident Attendance Program (RAP) for our summer meeting, and Resident Case Display. ABO/ CDABO Resident Advocacy Program has been implemented, as well as the CDABO Mentor Program and a special breakfast with a Case Presentation Speaker. We have updated our website, and we continue to recruit younger members. The College also presented the Annual award that recognizes the best case report published in the American Journal of Orthodontics and Dentofacial Orthopedics the prior year. The judges for this award are College officers. This year’s College of Diplomates meeting is being held at the Resort at Squaw Creek located near Lake Tahoe in Olympic Valley, California from July 7-11. Tahoe is a place to re-group, re-focus and re-ignite that passion and conviction we have in our practices while enjoying lectures of research-oriented first rate speakers. I have been privileged to have my friend Dr. Eric Dellinger as our scientific chair. I have known Eric and his family since our early years in the College and consider him a lifelong friend. He has put together some great speakers. The theme of this year’s meeting is,
For our separate spouse and staff program, we have invited Financial Planner Rich Arzaga for Saturday morning July 8th. The officers who have worked diligently to make this year’s meeting a success are: The General Chair; Dr. Robert Vaught, Scientic Chair; Dr. Eric Dellinger, Social Chair; Dr. Seus Kassisieh, Children’s Chair; Dr. Dan Rejman, Golf Chair; Dr. Bruce Goldstein, Logo & Fun Run Chair; Dr. John Carter. Special recognition to College of Diplomates Executive Director, Scott Cant, Executive Meeting Planner, Darrin Crittington, and Executive Secretary Jan Beck for their outstanding contributions. Remember, lectures are in the morning and leisure time is in the afternoon with your friends and family. Registration materials are posted at www.cdabo.org. Orthodontists who are not board certified can attend one time to evaluate the meeting and, hopefully, this will convince you to become board certified and join our family reunion. “Controversies: Stability of the End Result”. We will be honoring Dr. Wick Alexander for his exceptional commitment and lifetime achievements in our profession. Wick is a true “Legend in Orthodontics”. Other speakers include Dr. William Proffit, Dr. Jason Cope, Dr. Peter Buschang, Dr. Perry Opin, Dr. James Vaden, and Dr. Gary Opin (twelve CE credits are earned).
See You in Lake Tahoe,
Dr. Paul E. Miller
President, College of Diplomates of the American Board of Orthodontics
A BIT OF HISTORY ABOUT LAKE TAHOE
Back in the old days, summer vacationers began arriving more than 10,000 years ago when the American Indian Washoe tribe camped along the cool lakeshores. One of their favorite places is known today as Camp Richardson in South Lake Tahoe. This area is an education in itself. (The Profile Chamber is located near here) The first European American to see Lake Tahoe was John C. Fremont, whose exploration party was led by Kit Carson in 1844.
Lake Tahoe’s history is one for the storybooks. Lake Tahoe’s elevation is 6,229 feet, making it the highest lake of its size in the United States. The water depth measures 1,645 feet at a portion of the lake in the Crystal Bay area, making it the tenth deepest lake in the world and third deepest in North America. Lake Tahoe also boasts of water clarity to a depth of 75 feet. The lake covers a surface area of 191 square miles with 71 miles of shoreline, while the Nevada/California border traverses lengthwise with a greater portion being on the California side. (You can bike around Lake Tahoe! The ride is called the Tour de Tahoe Course. The 72-mile Tour de Tahoe – Bike Big Blue course circumnavigates the highways clockwise around Lake Tahoe in both Nevada and California and it has some challenging climbs. The rise includes a Emerald Bay and also Spooner Junction.) Average snowfall in some areas is 300-600 inches and melting snow finds its way to the lake via 63 streams entering the basin. (This has been a great snow year and Lake Tahoe is full to the brim!)
In 1859, the discovery of the Comstock Lode in Virginia City changed the face of the lake and would affect it forever. With mines, towns and the railroad invading the territory, wood was the primary fuel source and was also needed to supply building materials. The east shore, from what is now Incline Village to Glenbrook, became a vast logging empire and the ravages of clear-cutting would remain evident for years to come. The Comstock silver lode made hundreds of people wealthy during the California and Comstock mining days and many were attracted to the pristine lake. The Tahoe Basin managed to remain in relative obscurity with only a few people knowing about its existence until the 1950s when Bill Harrah and Harvey Gross built the first casinos on the south shore. With their gaming expertise, learned over the years back in Reno, Harris & Gross knew how to attract business for their establishments and became mainstays up until today. (Harvey’s and Harrah’s)
What would strike you as odd is the fact that there is only one outlet, the Truckee River. (The river is flowing well and should provide some great rafting during the meeting!)
Back in 1960, the Winter Olympic Games were hosted at Squaw Valley on the west shore. With the resulting publicity, the area was soon recognized as a world-class winter playground, as well as the premier summer vacation venue.
Because of the huge volume and constant movement of the water, Lake Tahoe never freezes despite the drastic winter temperatures.
The Olympic Rings still remain at Squaw Valley Resort and the place is renowned for year-round sporting activities.
Western Slope – South Shore
Sunset near Incline Village
WHY TAHOE? Located between the borders of California and Nevada, Lake Tahoe boasts over 300 days of warm sunshine, 396 inches of annual snowfall, 18 world-class ski and snowboarding resorts, incredible golf courses, fantastic restaurants, casinos, world renowned hiking, water rafting, biking and much more. There are many US air carriers that all serve the Reno-Tahoe International Airport such as American Airlines, United Airlines, Delta Airlines, as well as stopovers by Alaska, Frontier and Southwest. From the airport, rental cars and express bus service are the best way to travel to the lake. Driving time to the Squaw Creek Resort is about 45 minutes.
One of the most notable casinos in the Tahoe area is the Cal-Neva Lodge, which was famous for hosting the rich and famous. Frank Sinatra, once a part owner, and Marylin Monroe were common faces here, while former president John F. Kennedy also enjoyed spending time at this famous establishment located about 30 minutes from the Resort. Many big screen films and television shows have been to various filming locations in majestic Lake Tahoe. To name only one, the famous Ponderosa Ranch of the TV series Bonanza is actually located on the Nevada side of Lake Tahoe. Another bit of film trivia is that the opening sequence of the famed TV series was filmed at McFaul Creek Meadow with the beautiful Mount Tallac in the background.
In the highly acclaimed motion picture The Godfather Part II, the Corleone family lived in a compound on the shores of the Nevada side of Lake Tahoe. In one of the famous scenes during the final minutes of the film, Fredo Corleone is taken out onto the lake for a fishing trip. On the orders of his brother, Michael (Al Pacino), he is executed for treachery, where Michael stands by the shore watching the deed being done.
The house and grounds portrayed in the film are also located on the California side of Lake Tahoe in the summer estate of Henry Kaiser known as Fleur du Lac. The only structures used in the movie that still remain are the complex of old native stone boathouses with wrought iron gates. Fleur du Lac is private property, no one is allowed ashore there. The boathouses and multi-million dollar condominiums are easily viewed from the lake.
Fire Sign Cafe 1785 West Lake Blvd. Tahoe City, CA 96145 (530) 583-0871 Located 2 miles south of Tahoe City www.firesigncafe.com
The Pfeifer House, Inc. A good bet is the Hungarian Beef Goulash with egg noodles or any of the Schnitzel choices. Don't forget to try the potato pancakes and spatetzle dumplings. Finish your meal with some old fashioned Bavarian apple strudel. Of course, a children's menu is available. If you have never had german beer in a glass boot then you are in for a treat! Call and make reservations (530) 583-2102. 15 Minutes from Squaw Creek Resort 760 River Road (Highway 89 South), Tahoe City, CA 9614 pfeiferhouse.com
PLACES TO DO THINGS
THINGS TO DO ON THE WATER
LOOKING FOR SOMETHING TO DO WITH THE FAMILY
PLACES TO HIKE
TRUCKEE RIVER RAFTING
PLACES TO VISIT
(Try this – the water is only 2 feet deep so if you fall in you can find your valuables and swim trunks if necessary)
Canoe & kayak tour agency in Tahoe City, California Address: 55 W Lake Blvd, Tahoe City, CA 96145 Phone: (530) 583-7238 15 Mins from Squaw Creek Resort http://www.truckeeriverrafting.com/index.php
39TH ANNUAL MEETING SCIENTIFIC SPEAKER LIST Dr. Wick Alexander Dr. William Proffit Dr. Peter Buschang Dr. James Vaden
Dr. Jason Cope Dr. Perry Opin Dr. Gary Opin
SPOUSE & STAFF PROGRAM Rich Arzaga, CFP, CCIM
MEETING SCHEDULE C O N T R O V E R S I E S : S TA B I L I T Y O F T H E E N D R E S U LT SATURDAY, JULY 8, 2017 7:00am- 12:00nn
General Session 9:00am - 9:15am
9:15am - 10:30am
Temporary Replacement of Missing Maxillary Lateral Incisors with Orthodontic Mlnlscrew Implants in Growing Patients: Rationale, Clinical Technique, and Results Dr. Jason Cope
10:30am - 10:45am
10:45am - 11:00am
Morning Coffee Break
ALPINE AB FOYER
11:00am - 12:15pm
Non-Surgical Tad Open Bite Closure With Long Term Stability Dr. Jason Cope
12:15pm - 12:30pm
Social Programs 7:15am - 9:00am
10:00am - 11:00am
1:00pm - 5:00pm
(Plated breakfast for all registered family attendees.)
Destination Tahoe GroupTour The Thunderbird Lodge Tour Horseback Riding Hiking Adventure – Beginning
REGISTRATION DESK / ALPINE PRE-FUNCTION
Opening Family Breakfast
R E U N I O N O F T H E D I P L O M AT E S SUNDAY, JULY 9, 2017 700am -12:00nn
General Session 8:15am - 9:30am
Is Long Term Stability (LTS) in Your Treatment Plan Dr. Wick Alexander
9:30am - 9:45am
9:45am - 10:00am 10:00am - 10:30am
Morning Coffee Break
ALPINE AB FOYER
The College - Business Meeting 1 Honoray Lecture Raymond Thurow
10:30am - 11:45am
How Do You Orthopedically Correct a Hyperdivergent Retrognathic Mandible and Ensure that the Changes Remain Stable? Dr. Peter Buschang
Social Programs 6:30am -7:30am
Fun Run/Walk (Additional
fee required, sign up on the College Registration
7:00am - 9:00am 9:00am - 11:00am 10:00am - 11:00am
1:00pm - 5:00pm
1:00pm - 5:00pm
Family Breakfast Buffet (All registered family attendees included.)
The College Scavenger Hunt (Children’s Program, ages 5-12 years old.)
MEET IN RESORT LOBBY MONTAGNA MOUNTAIN BUDDIES
Destination Tahoe Group Tour White Water River Rafting Historic Donner – Truckee Shopping Tour with Lunch at Dragonfly Sailing Adventure
REGISTRATION DESK / ALPINE PRE-FUNCTION
Golf Tournament Additional Fee required, sign up on the College Registration Form.
LINKS AT SQUAW CREEK
C O N T R O V E R S I E S : S TA B I L I T Y O F T H E E N D R E S U LT MONDAY, JULY 10, 2017 7:00am-I2:00nn
General Session 8:00am - 9:15am
Impactions, Impactions. Why Me? Dr. Perry Opin
9:15am - 9:30am
9:30am - 10:00am
The College - Business Meeting 2
Morning Coffee Break
ALPINE AS FOYER
10:15am - 11:30am
Outcomes with Modern Treatment of Severe Open Bite Dr. William Proffit
11:30pm - 11:45pm
12:15pm - 1:00pm
Alexander Wick Reception
Social Programs 7:00am - 9:00am
Family Breakfast Buffet (All registered family attendees included.)
1:00pm - 5:00pm
Destination Tahoe Group Tour The Thunderbird Lodge Tour Horseback Riding Hiking Adventure – Beginning
REGISTRATION DESK / ALPINE PRE-FUNCTION
600pm - 9:00pm
10:00am - 11:00am
R E U N I O N O F T H E D I P L O M AT E S TUESDAY, JULY 11, 2017 7:00am -1:00pm
General Session 8:30am-9:45am 9:45am-10:00am
Stability - It Begins with the Treatment Plan Dr.James Vaden
Morning Coffee Break
ALPINE AB FOYER
Medical Therapy Dogs in Orthodontic Practices and How It WiII Make Your Practice Better Dr. Gary Opin
Social Programs 7:00am-9:00am
Family Breakfast Buffet (All registered family attendees included.)
E X P E R I E N C E T H E R E S O R T AT S Q U AW C R E E K , L A K E TA H O E
Dr. David Hatcher & Dr. Shikha Rathi PRIVATE PRACTICE, DIAGNOSTIC DIGITAL IMAGING, SACRAMENTO, CA, USA
HIGH VALUE SCENARIOS FOR CBCT IMAGING IN ORTHODONICS Imaging is utilized in orthodontics as a tool to acquire anatomic information for diagnosis, treatment planning and treatment assessment. Imaging strategies for orthodontics have been well defined for decades. In North America, this paradigm changed in 2001 when cone beam computed tomography (CBCT) was introduced into the market place. Drs. Ivan Dus, Joe Caruso and Carl Gugino, all orthodontists, were instrumental in shepherding CBCT to the United States from Europe. The adoption of CBCT gained momentum in 2004 as second generation instruments became smaller, less expensive and provided higher quality images. Research studies defined the parameters to provide optimal images in clinical practice including patient dose. Best practices for diagnostic imaging are determined on a case by case basis following a clinical exam and histo-
ry. Once imaging goals are established the appropriate images can be obtained. For example, the imaging goals for an impacted tooth may include localization of the impacted tooth relative to adjacent teeth and structures, determine the etiology of the impaction, identify or rule out any associated pathosis and design the traction mechanics and surgical access for the forced eruption therapy. Once the imaging goals are established the clinician can choose the imaging modality that produces the desired diagnostic yield with minimal dose and cost. The intent of this article is to outline clinical phenotypes that may benefit from CBCT imaging. Patient phenotypes include mandibular asymmetry, open bite, clockwise facial growth patterns (dolichofacial), impactions, and craniofacial malformations. CBCT may be utilized to asses TMD patients and airway.
DOLICHOCEPHALIC PHENOTYPE The assessment of facial morphology is important for the planning and prognosis of orthodontic treatment. Facial type and growth pattern has an influence on jaw size and dentoalveolar housing, occlusion type, anatomy and function of the masticatory muscles, and volume and shape of the pharyngeal airway.
Patients with a long dolichocephalic face with high angle (SN-MP ≥ 39⁰) hyperdivergent vertical facial growth pattern often show the following characteristics: • Convex facial profile • Small, recessive mandible • Steep mandibular plane • Clockwise facial growth (posteroinferior rotation of the mandible) • Increased lower anterior face height • Skeletal anterior open bite • Narrow antero-posterior dimension of the bone in the anterior mandible1, 2 • Reduced antero-posterior dimension of the oropharyngeal airway, which in more severe cases may result in the development of sleep apnea symptoms3-8 • Forward head posture to compensate for a narrowed airway • Higher probability of degenerative or inflammatory disorder of the TMJs1, 9
Figure 1: Cone-beam CT (CBCT) images of a young female with (A) a dolichocehalic facial growth pattern with convex facial profile. (B) CBCT-reconstructed panoramic image showing small condyles, small rami, steep mandibular planes and pronounced antegonial notching on both sides. (C) Sagittal and coronal images showing small condylar processes indicative of end-stage juvenile DJD (or progressive condylar resorption, PCR)). (D) A volumerendered lateral view showing posteroinferior rotation of the mandible, short rami and steep mandibular planes. (E) Midsagittal view showing marked narrowing of the alveolar ridge in the anterior mandible. The alveolar housing for the teeth is reduced and such teeth are susceptible to external resorption with orthodontic treatment.
It is important to note that disturbances in condylar growth influences maxillofacial growth and development and result in a change in growth pattern in a young individual. 9, 10 Condylar shortening and reduced condylar development can result in a clockwise facial growth or clockwise rotation of the mandible around molar fulcrums and lead to dentoalveolar compensation. Therefore in dolichofacial patients it is important to identify or rule out a TMJ disorder and determine its activity status, if present. A CBCT evaluation of dolichocephalic individuals usually shows TM Disorder characterized by small condyles with loss in volume from the superior aspect, the degree of which depends on the onset age of the disease process and its severity. The anterior region of the
mandible in dolichocephalic individuals often has an increased vertical dimension and a small anteroposterior dimension therefore creating an orthodontic treatment risk including periodontal bone loss, partially moving teeth out of the alveolar housing and external root resorption.1 The clockwise rotation of the mandible in dolichocephalic individuals may be associated posteroinferior positioning of the tongue and a reduction in airway dimensions. A CBCT scan helps in identifying and quantifying the unique characteristics associated with dolichocephalic phenotypes that are often masked by superimposition of structures in conventional 2D images. 3D analysis can help plan treatment strategies, timing, and predict success outcomes in such cases.
Figure 2: (A) Patient with a convex facial profile with a long lower anterior face height. (B) Frontal photograph of the occlusion showing an asymmetric anterior open bite. (C) Sagittal images of the anterior mandible showing a narrow and elongated alveolus with labial displacement of the incisors beyond the cortical boundaries. The limited alveolar dimensions restrict the extent of orthodontic movement of the teeth. Apical root resorption is present on the teeth due to their orthodontic displacement beyond the alveolar confines.
MANDIBULAR ASYMMETRY Symmetry assessment is an integral part of comprehensive orthodontic evaluation. The role of 2D radiographs in the study of localization and quantification of asymmetric deformities is limited due to the geometric complexity of the involvement of the dentition and the hard and soft tissues associated with asymmetries. The goals of imaging a mandibular asymmetry include determination of the etiology and activity state of the asymmetry and a component analysis of the craniofacial skeleton to identify the associated anatomic elements.
a discrepancy in the dimensions of the mandibular ramus and body, a difference in the steepness or curvature of the mandibular plane and the depth of the antegonial notch. The transverse dimension of the mandible is also frequently affected along with a corresponding effect on the occlusion. The condyle and the associated growth site are the cornerstones of mandibular growth. An insult to the condyle during growth and development has the potential to retard development of the condyle and ipsilateral half of the mandible. The severity of the asymmetry is directly proportional to the potency of condylar insult and inversely proportional to age of onset.
Mandibular asymmetry is typically associated with altered TMJ morphology and/ or function that may be secondary to a degenerative disorder11 (most common), inflammatory disorders, condylar fracture, condylar hyper- or hypoplasia, hemimandibular elongation, condylar dislocation, or a TMJ neoplasia. Additional etiology for a mandibular asymmetry may include hemifacial microsomia, an expansile mandibular lesion, or a mass adjacent to the mandible. The most common characteristics associated with asymmetries include a deviation of the skeletal and/or dental midline, a cant in the occlusal plane,
3D imaging has high value in identifying the cause of mandibular asymmetry and in analyzing the various components affected by the asymmetry. Imaging information is useful in treatment planning for orthodontics and/or orthognathic surgery. Imaging information assists by characterizing the status of the TMJ condition responsible for the asymmetry and in determining whether it may be progressive or stable. In contrast, conventional 2D imaging offers limited assessment of the TMJ osseous contours and morphology and spatial relationships and quantifying the severity of the regional effects.
Figure 3: Hemimandibular elongation (A) Facial photograph of a 19 yo female showing mandibular asymmetry with the right side shorter than the left. The lip commissure is elevated on the right side. (B) Frontal phototograph of the occlusion shows a deviation of the mandibular midline to the right and a posterior cross-bite on the right. (C) A CBCT-reconstructed panoramic shows smaller dimensions of the right condyle and ramus, steeper mandibular plane and an elevated occlusal plane on the right. (D) TMJ coronal and sagittal images show a discrepancy in the overall dimensions of the condyles with the right condyle being smaller than the left. (E) Volume rendered CBCT shows a frontal and lateral view with a skeletal asymmetry. The osseous and dental midline of the mandible is shifted to the right. The lateral development of the right half of the mandible is less than the right. The occlusal plane is elevated on the right side. The angle of the mandible is superior on the right side and a discrepancy in the size of the mandibular body is evident.
ACQUIRED CHANGE IN OCCLUSION Malocclusions occur for several reasons and are highly prevalent in the general population. Infrequently, certain types of malocclusions result from growth and developmental abnormalities in the TMJ. A helpful clue in identifying an underlying TMJ anomaly as a possible contributor to malocclusion is an acquired and progressive change in bite. Open bites can be unilateral, bilateral and involve the anterior or posterior teeth. OPEN BITE Anterior open bites frequently result from tongue thrust or non-nutritive sucking habits. If the tongue thrust develops at an early age, mammelons may be present on the anterior teeth. With a sucking habit, there may be an increase in the anterior overjet along with a proclination of the incisors. A sucking habit may also predispose a patient to develop a posterior cross-bite and a Class II canine and molar relationship. Several studies have shown an association of an acquired anterior open bite with TMJ osteoarthritis.12-15 The development of an open bite is considered to be a consequence rather than an etiological factor for a TMJ disorder.13,14 Such cases often show limited mandibular development and a clockwise facial growth pattern, particularly if the onset of the TMD has been at a young age. 16 Conditions resulting in a loss of condylar volume such as degenerative disorders (adult or juvenile onset), rheumatoid arthritis, and juvenile idiopathic arthritis often show bilateral involvement with osseous destruction of the condyles originating on their superior surfaces. A dual bite is another acquired condition producing a change in occlusion. 17-19 A dual bite is produced by anterior posturing of the mandible which secondarily repositions the condyles anteroinferiorly in the fossa. The mandible is protruded and the incisors have an edge-to-edge relationship. This phenomenon can increase the vertical dimension of occlusion and produce a bilateral posterior open bite. Over time, the maxillary posterior teeth could supraerupt to be in occlusion; this results in a flat or reversed curve of Spee. At this stage, all teeth are in contact but the condyles are anterior in their fossa (a non-seated condyle is associated with an orthopedically unsta-
ble occlusion). Maintaining the forward mandibular posture can be difficult and may require excessive recruitment of the lateral pterygoid muscles. The dual bite can relapse or partially relapse by an autorotation of the mandible around the molar fulcrums as the condyles attempt to seat back in their fossa eventually producing an anterior open bite. The anterior open bite may be progressive as the condyles attempt to seat completely in their fossa. Further, it can result in occlusal wear of the posterior teeth. The dual bite phenomenon produces a bilateral posterior open bite in its early stage and a progressive anterior open bite in its later stage.17, 19 Although the condyles are initially anteroinferiorly positioned in their respective fossa and are later seated at the center of the fossa, there is usually no change in the size and shape of the condyles. Imaging can play a role in understanding the cause for the dual bite. Anterior open bite may also result from nasal obstruction in a mouth breather. In addition to obstructed nasal fossa and/or nasopharynx (from enlarged adenoids), such patients frequently show transverse narrowing of the maxilla, a high palatal vault, and a long face (often referred to as ‘adenoid facies’) with possible clockwise facial growth pattern. A common cause of a unilateral posterior open bite is loss in condylar volume on the contralateral side. This may result from a subcondylar fracture or a unilateral degenerative or inflammatory disorder of the TMJ. The biomechanics of the jaw joints work such that the principal muscle vector tends to seat the shortened condyle in its fossa thus shifting the mandible to the ipsilateral side and creating a contralateral open bite. Less common causes for a unilateral posterior open bite include a condylar hyperplasia or neoplasia on the ipsilateral side. Bilateral posterior open bites are an uncommon occurrence and may develop with long-term use of an occlusal appliance that positions the mandible forward (i.e., anterior positioning type, sleep apnea appliance). An uninterrupted use of a posterior coverage appliance may result in intrusion of posterior teeth and/or overeruption of anterior teeth that may lead to the development of a posterior open bite. A posterior open bite may be observed early, prior to developing a dual bite (see above) or rarely in cases of acromegaly.
CROSS-BITE AND/OR A CANT IN OCCLUSAL PLANE
A cross-bite or a cant in the occlusal may develop for reasons similar to those causing a unilateral posterior open bite. Conditions that occur during the period of somatic growth in which condyles are reduced in the vertical dimension, such as degenerative or inflammatory disorder, condylar hypoplasia, subchondral fracture, may result in a shift in the mandible to the shorter side and development of a cross-bite or an elevation of the occlusal plane on the ipsilateral side. Other conditions in which the condylar dimensions are increased, such as in condylar hyperplasia or neoplasia, may produce a shift in the mandible to the opposite side resulting in a contralateral cross-bite and/or a depression of the occlusal plane on the ipsilateral side. Hemimandibular elongation (Case 3), a developmental condition, will often be associated with a contralateral cross bite, negative anterior over jet, shift of the mandibular dental and osseous midline to the contralateral side and vertically elongated ipsilateral condylar process.
An association between an altered/ reduced mandibular growth and TMJ disorders is well-established in the literature. The most important of these is degenerative joint disease, 9-11 and juvenile idiopathic osteoarthritis. 21-23 A clinical presentation of pain or discomfort in the TMJ area, limitation of opening, acquired/ progressive change in bite may point to an underlying TMJ disorder and warrants further evaluation. An accompanying asymmetry or mandibular growth deficit further underscores the need for investigation to achieve the correct diagnosis prior to treatment. A joint that is unstable may continue to breakdown if subjected to orthodontic forces and result in failure or relapse of orthodontic treatment. These joints require monitoring until the disease process is stabilized. A joint that has undergone previous wear but has now attained stability may not tolerate occlusal forces to the same capacity as a robust joint. It is important to identify such cases and inform patients of the compromised load bearing capacity of their joints and the possibility of re-initiating the condylar breakdown process with increased stresses on the joint, which may continue to occur after orthodontic treatment is complete.
Palatal cross-bites and reduced dentoalveolar transverse widths in the maxilla and mandible are also shown to be associated with a reduction in the nasopharyngeal and oropharyngeal sagittal dimension and sleep disordered breathing (SDB) in children.20
Figure 4: (A) Frontal and profile photographs of a 16 yo female with a dolichocephalic convex facial profile. (B) Frontal, left lateral and maxillary occlusal photographs of the teeth showing a narrow maxillary arch with a deep palatal vault, an increased anterior overjet and an anterior open bite. (C) CBCTreconstructed panoramic image showing short condyle and rami, steep mandibular planes and a pronounced antegonial notch on both sides. (D) Coronal and sagittal view of the right and left TMJs show small condyles indicative of end-stage The osseous findings in the TMJ are consistent with progressive condylar resorption, PCR (a juvenile form of degenerative joint disease, DJD) that is radiographically stable at this time. (E) A midsagittal and a volume rendered view of soft and hard tissues show reduction in the anteroposterior dimensions of the pharyngeal airway.
AIRWAY EVALUATION Cone beam imaging for the primary reason of airway evaluation has been greatly debated. Studies have shown that certain craniofacial patterns are related with smaller dimensions of the upper airway24, some of the most common of which include: • Mandibular deficiency and retrognathia • Steep mandibular plane,4-6 • Maxillary hypoplasia • Class II and hyperdivergent skeletal pattern3 • Reduced transverse dimension of the maxillary or mandibular ridge or crossbites20 • Inferior position of the hyoid • Clockwise rotation of the mandible • Longer lower anterior face height • Increased size of the tongue and soft palate
Individuals with the above features are at higher risks for the development of obstructive sleep apnea (OSA), and is most notable in Asians.7,8 Small jaws provide insufficient space for the tongue which may as a consequence be posteriorly positioned causing crowding of the airway. Individuals with a dolichocephalic facial growth pattern that exhibit clockwise rotation of the mandible often have inferiorly positioned hyoid bone. The genioglossus and the geniohyoid muscles attach the mandible to the tongue and the hyoid bone respectively; as such, conditions that retract the mandible or hyoid bone have a negative impact on the pharyngeal airway. This has been documented in clinical conditions of depressed consciousness in which airway obstruction is overcome by moving the jaw forward. 25 Since mandibular growth has been linked to condylar growth, and a the most frequent cause of reduced condylar growth is a degenerative joint disease (DJD, aka, osteoarthritis), it is reasonable to correlate a developmental onset of DJD with a reduction in airway dimensions.26 3D imaging provides new possibilities for airway study, in terms of better understanding of its working and provides added value in cases suspected of OSA. It permits the study of size and shape of airway di-
mensions with linear, cross-sectional, and volumetric analysis, presence and size of tonsils and adenoids, size of the tongue and soft palate, jaw position and jaw size in antero-posterior and transverse dimensions, nasal anatomy and obstruction, relationship of cervical spine to airway, and the presence of any pathology encroaching the airway. CBCT imaging cannot however confirm or exclude the diagnosis of OSA; a laboratory-based polysomnogram is the gold standard to establish such as diagnosis. A lateral cephalogram is limited in airway evaluation in that it only reflects the linear antero-posterior dimension. The transverse dimension of the airway along with possible obstruction as a result of enlargement of the palatine tonsils (which arise from the lateral pharyngeal walls) is limited in a lateral cephalogram. Although CBCT has several advantages over other imaging modalities, scans taken in an upright position with the patient in a state of consciousness reportedly underestimate the airway dimensions during sleep. This could imply that a small airway (cross-sectional dimension <110 mm2) on a CBCT scan has a greater likelihood of being associated with OSA.27-30
IMPACTED OR SUPERNUMERARY TOOTH LOCALIZATION AND ASSESSMENT OF ROOT RESORPTION With an incidence of 1-3%31,32, the maxillary canine is the second most frequently impacted tooth after third molars33,34 and perhaps the most common reason for the use of CBCT in orthodontics. Most impacted canines are palatally positioned, particularly in white patients35,36 but may be more frequently labially positioned in Asians.37 The use of CBCT provides precise localization and orientation of impacted teeth and their proximity to roots of adjacent teeth and important anatomic structures such as the incisive canal, maxillary sinus and floor of the nasal cavity. The presence and extent of external resorption on neighboring teeth, evaluation of follicular size and pathology, and assessment of space restrictions can be accurately diagnosed by CBCT images. Several studies have shown that the use of CBCT increases the confidence and accuracy in diagnosis of impacted teeth and results in changes in treatment decisions and outcomes when compared to conventional 2D imaging modalities38-43 in addition to reducing treatment duration44. CBCT images can be used to assess the distance between an impacted canine from the midline and the occlusal plane, the an-
gulation, curvature, and morphology of the canine and the adjacent roots and estimate the amount of bone surrounding the impacted tooth; all of which can be deciding factors in treatment planning. Other treat-
ment decisions including creating tooth space, facilitating spontaneous tooth eruption and planning surgical exposure and bonding for optimal extrusion of teeth can also be aided by CBCT images.
View from top
Figure 5: (A) A CBCTreconstructed panoramic image showing impacted teeth #7, 8, 10. (B) Segmented 3D model shows the impacted teeth in green. Such a model can be rotated on screen to be viewed from different angles and provides a clear visualization of the impacted teeth in relation to adjacent teeth and anatomic structures.
Right lateral view
Incisor root resorption, when associated with an impacted cuspid, is seen as many as 38% of patients45 and often remains asymptomatic.46 The resorption may be progressive and could compromise the longevity of the tooth. 2D imaging is limited in diagnosing buccal and lingual resorption defects47 and de-
fects smaller than 0.6 mm in diameter and 0.3 mm in depth. 48,49 Previous studies have shown CBCT to be superior to conventional imaging in determining the location and nature of the resorption and its precise extent.50-53
Figure 6: (A) A CBC-generated panoramic image showing impacted tooth #6 superimposed over the roots of #7, 8. (B) A sagittal view shows external resorption of the palatal half of the root of #8 due to proximity to the crown of #6. (C) A segmented 3D model shows a similar view of the extensive palatal resorption of #8 and the relationship of #6 and #8.
The accurate positional diagnosis of an impacted tooth and determining its relation with the adjacent structures is essential in deciding the best treatment option for a successful outcome. An earlier detection may prevent root resorption in adjacent teeth and support timely treatment planning. By minimizing superimpositions and distortions present in 2D imaging modalities, and enhancing visualization with
submillimeter accuracy, CBCT enables superior diagnostic capabilities for management of impacted teeth. For the same reasons, CBCT enhances diagnostic accuracy and treatment options in comparison to conventional 2D imaging for evaluation of supernumerary teeth â&#x20AC;&#x201C; providing its 3D localization, morphological assessment, and detection of pathology or adjacent teeth resorption.
Figure 7: (A) Frontal and maxillary occlusal photographs showing a supranumerary tooth bought into occlusion on the palatal aspect of the ridge in the region of impacted #8. A temporary crown has been fabricated in the region of #8 for esthetic purposes. (B) 3D segmented model show the relationship of the supernumerary tooth (in orange) with impacted #8 (in yellow). The root of #7 is palatally tipped and the root of the supernumerary is positioned labial to it. (C) Cross-sections of the anterior maxilla and a panoramic reference image show the labio-palatal relationship of the teeth #7, 8, 9 and the supernumerary. The root of the supernumerary projects out of the labial cortex. Orthodontic treatment in this case was initiated prior to acquiring a CBCT scan which led to mis-interpretation and orthodontic exposure of the supernumerary instead of #8.
Figure 8: (A) CBCT-generated panoramic showing pathology in the left anterior maxilla and impacted teeth #10, 11, 13. Tooth #12 is absent and primary teeth G, H, I, J are retained. (B) Volume rendered images show the relationship and angulation of the impacted teeth #10, 11, 13 to the dense heterogeneous mass (consistent with a complex odontoma). (C) Axial and sagittal image show the composition of the mass and its relationship with #10, 11.
Use of a small field of view (FOV) CBCT scan is justifiable in all but superficial cases of impactions and has a high yield in the following scenarios:
forming the images, the 2D modalities such as panoramic and cephalograms, are geometrically inaccurate in elucidating the acquired anatomy.57-59
• when the apex of the impacted cuspid is not clearly discernable and its relationship with the apices of the adjacent teeth (bicuspid or incisor) and anatomic structures (maxillary sinus, incisive canal, nasal floor) is questionable
Although cone-beam CT has not been established as a standard choice of imaging in orthodontics, it is superior to 2D radiographs in geometric accuracy and reliability of measurements. A single CBCT scan provides an accurate inter-relationship of anatomic structures and permits assessment of areas of interest with submillimeter accuracy. The acquired field of view (FOV) can be scaled to match the regions of interest, which may range for a small dentoalveolar area to the entire craniofacial region. Software capabilities permit visualization of a CBCT scan from any angle and specific areas in a scan can be segmented for further analysis. With the ongoing improvement in hardware technology, numerous CBCT units with dose reduction protocols have been introduced. A study by Ludlow and Walker60 reported that the effective dose of radiation of CBCT for a full head scan with low-dose settings may be reduced to the level of a panoramic examination, but at the expense of lower image quality. Moreover, the improved diagnostic yield from a single CBCT must be weighed against quality of output and the sum of radiation doses from panoramic, cephalometric, and periapical radiographs that are routinely employed in orthodontics.
• external root resorption of adjacent teeth is suspected • ankylosis or root dilaceration is suspected • follicular enlargement or pathology is suspected • when canine inclination in the panoramic exceeds 30 degrees relative to a perpendicular midline54 • in the presence of a supernumerary tooth In cases of impacted third molars that are indicated for removal prior to orthodontic treatment, pre-operative assessment CBCT imaging should be considered when boundaries of the mandibular canal are partly or completely superimposed over the root. The radiographic signs for such high risk cases may include55: • Loss in continuity of the walls of the mandibular canal • Diversion of the mandibular canal • Narrowing of the mandibular canal • Change in density of the roots of the third molar
Based on the scientific evidence available, use of cone-beam CT has high yield in orthodontic diagnosis and increased treatment effectiveness in the following clinical presentations: • Dolichocephalic facial type with clockwise rotation of mandible • Asymmetry
• Narrowing of the roots of the third molar
• Acquired and/or progressive occlusal changes such as development of open bite, cross-bite, asymmetric occlusal plane
• Deflection of the roots of the third molar56
CONSIDERATIONS FOR USE OF CBCT IN ORTHODONTICS The ultimate goal of imaging is to portray the anatomic truth to help in diagnosis and treatment planning. 2-dimensional imaging modalities provide patchwork information of different segments to represent 3-dimensional anatomy. Because of the nature of acquisition and multiple sources of error incorporated in
• Additional indicators of underlying TMJ anomaly such as limited opening, joint pain and noises, jaw locking • Suspected airway problems as suggested by patient history and craniofacial deformities associated with a small airway • Impacted and supernumerary teeth suspected of associated resorption or pathology, or, in the
case of third molars, in close proximity to the inferior alveolar canal • Craniofacial malformations such as cleft lip/ palate, syndromic anomalies • Severe skeletal discrepancy that would require orthognathic surgery In addition to the many applications of CBCT in different fields of dentistry, the scans frequently pick up incidental findings in areas outside of the region of interest. These incidental findings occur in the paranasal sinuses, airway or skull base and can have significant impact on a patient’s health and well-being.
C Figure 9: (A) Facial, profile and intraoral photographs of a young female referred for a CBCT evaluation for impacted tooth #22. The patient has limited oral opening and a forward head posture. (B) A CBCT-reconstructed panoramic shows an impacted #22 with the crown superimposed over the roots the mandibular incisors. (C) Coronal and axial views show an incidental airway asymmetry with a large soft tissue mass extending into the right nasopharynx and oropharynx. (D) Axial view of the skull base shows opacification of the right mastoid air cells. The patient was subsequently diagnosed to have a rhabdomyosarcoma, an invasive malignant lesion that had occupied much of the right half of the facial soft tissues.
Value of Common Imaging Modalities for Specific Diagnostic Tasks
Cephalometric (Lateral and/or AP)
TMJ osseous components
TMJ disc position and morphology
TMJ relation to maxillofacial complex
Facial skeleton symmetry
Transverse jaw assessment
The value of different TMJ imaging modalities for specific diagnostic tasks: X = no value; ✓ = low value; ✓✓ = moderate value; ✓✓✓ = high value; ✓✓✓✓ = highest value
33 Conclusions: CBCT, a widely available 3 dimensional imaging technique, provides an anatomic accuracy that is not achievable with conventional panoramic and cephalometric imaging and therefore has the potential to have unique clinical value in selected clinical scenarios. In addition, all of the anatomic structures of interest to the orthodontist are contained in one CBCT image volume thus providing the opportunity for more accurate assessment than 2 D imaging of the anatomic and functional inter-relationships between craniofacial structures. This article proposes and discusses selected clinical scenarios that may uniquely benefit the patient and orthodontist by choosing CBCT as the preferred imaging modality.
Gracco A, Lombardo L. Computed Tomography evaluation of mandibular incisor bony support in untreated patients. Am J Orthod Dentofac Orthoped 2010; 138,2:179-185
Zhang J, Chen G, Li W, Xu T, Gao X. Upper Airway Changes after Orthodontic Extraction Treatment in Adults: A Preliminary Study using Cone Beam Computed Tomography. Cray J, ed. PLoS ONE. 2015;10(11):e0143233.
Zicari AM, Duse M, Occasi F, Luzzi V, Ortolani E, Bardanzellu F, et al. Cephalometric pattern and nasal patency in children with primary snoring: the evidence of a direct correlation. PLoS One. [Journal Article]. 2014. 2014-0120;9(10):e111675 doi: 10.1371/journal.pone.0111675
Deng J, Gao X. A case—control study of craniofacial features of children with obstructed sleep apnea. Sleep Breath. [Journal Article; Research Support, Non-U.S. Gov’t]. 2012. 2012-1201;16(4):1219–27
Roedig JJ, Phillips BA, Morford LA, Van Sickels JE, Falcao-Alencar G, Fardo DW, et al. Comparison of BMI, AHI, and apolipoprotein E epsilon4 (APOE-epsilon4) alleles among sleep apnea patients with different skeletal classifications. J Clin Sleep Med. [Comparative Study; Journal Article; Research Support, N.I.H., Extramural]. 2014. 2014-04-15;10(4):397– 402. doi: 10.5664/jcsm.3614
Sutherland K, Lee RW, Cistulli PA. Obesity and craniofacial structure as risk factors for obstructive sleep apnoea: impact
Hoang, Nga. Evaluation of Mandibular Anterior Alveolus in Different Skeletal Patterns. University of California, San Francisco, ProQuest Dissertations Publishing, 2013. 1541884.
of ethnicity. Respirology. [Journal Article; Review]. 2012. 201202-01;17(2):213–22. doi: 10.1111/j.1440-1843.2011.02082.x 8.
Lee RW, Vasudavan S, Hui DS, Prvan T, Petocz P, Darendeliler MA, et al. Differences in craniofacial structures and obesity in Caucasian and Chinese patients with obstructive sleep apnea. Sleep. [Comparative Study; Journal Article; Research Support, Non-U.S. Gov’t]. 2010. 2010-08-01;33(8):1075–80. Olcay Sakar, Funda Çalisir, Evren Öztas & Gülnaz Marsan. Evaluation of the Effects of Temporomandibular Joint Disk Displacement and Its Progression on Dentocraniofacial Morphology in Symptomatic Patients Using Lateral Cephalometric Analysis, CRANIO®2011, 29:3, 211-218, DOI:10.1179/ crn.2011.030
10. Nebbe B, Major PW, Prasad NG: Adolescent female craniofacial morphology associated with advanced bilateral TMJ disk displacement. Eur J Orthod 1998; 29:701-712 11. Zou B, Kim TW, Choi SC. Morphologic and positional assessment of temporomandibular joint disk in facial asymmetric patients by magnetic resonance imaging. Korean J Orthod. 2005 Oct;35(5):398-407 12. D.A. Seligman, A.G. Pullinger. The role of intercuspal occlusal relationships in temporomandibular disorders: a review. J Craniomandib Disord, 5 (1991), pp. 96–106 13. A.G. Pullinger, D.A. Seligman, J.A. Gornbein. A multiple logistic regression analysis of the risk and relative odds of temporomandibular disorders as a function of common occlusal features. J Dent Res, 72 (1993), pp. 968–979
14. Chen, Y; Shih, T; Wang, J ; Wang, H ; Shiau, Y. Magnetic resonance images of the temporomandibular joints of patients with acquired open bite. Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology and Endodontology, 2005, Vol.99(6), pp.734-742
dibular growth rotation in patients with juvenile idiopathic arthritis followed from childhood to adulthood. Pediatric Rheumatology, 2010, Volume 8, Number 1, Page 13 22. Billiau AD, Hu Y, Verdonck A, Carels C, Wouters C: Temporomandibular joint arthritis in juvenile idiopathic arthritis: prevalence, clinical and radiological signs, and relation to dentofacial morphology. J Rheumatol. 2007, 34: 1925-1933. 23. Twilt M, Schulten AJ, Nicolaas P, Dülger A, van Suijlekom-Smit LW: Facioskeletal changes in children with juvenile idiopathic arthritis. Ann Rheum Dis. 2006, 65: 823-825. 10.1136/ard.2005.042671. 24. Neelapu BC, Kharbanda OP et al Craniofacial and upper airway morphology in adult obstructive sleep apnea patients: A systematic review and meta-analysis of cephalometric studies, Sleep Medicine Reviews, Volume 31, February 2017, Pages 79-90, ISSN 1087-0792, http://doi.org/10.1016/j. smrv.2016.01.007. 25. Liscott MS, Horton WC: Management of upper airway obstruction. In Yarington CT (editor): Otolaryngologic Clinics of North America. Philadelphia, 1979, WB Saunders 12: 351-373. 26. Hatcher, D.C., Progressive Condylar Resorption: Pathologic Processes and Imaging Considerations. Seminars in Orthodontics, 2013. 19(2): p. 97-105. 27. Lowe AA, Gionhaku N, Takeuchi K, et al. Three-dimensional CT reconstructions of tongue and airway in adult subjects with obstructive sleep apnea. Am J Orthod Dentofacial Orthop 1986;90(5):364–74. 28. Avrahami E, Englender M. Relation between CT axial cross-sectional area of the oropharynx and obstructive sleep apnea syndrome in adults. AJNR Am J Neuroradiol 1995;16(1):135–40.
15. S. Akerman, S. Kopp, M. Nilner, A. Petersson, M. Rohlin. Relationship between clinical and radiologic findings of the temporomandibular joint in rheumatoid arthritis. Oral Surg Oral Med Oral Pathol, 66 (1988), pp. 639–643
29. Ogawa T, Enciso R, Shintaku WH, et al. Evaluation of cross-section airway configuration of obstructive sleep apnea. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2007;103(1):102–8.
16. L. Olson, O. Eckerdal, A.L. Hallonsten, M. Helkimo, G. Koch, B.A. Gare. Craniomandibular function in juvenile chronic arthritis. A clinical and radiographic study Swed Dent J, 15 (1991), pp. 71–83
30. Hui Chen, Ghizlane Aarab, Maurits H.T. de Ruiter, Jan de Lange, Frank Lobbezoo, Paul F. van der Stelt, Three-dimensional imaging of the upper airway anatomy in obstructive sleep apnea: a systematic review, Sleep Medicine, Volume 21, 2016 j.sleep.2016.01.022.
17. Tamimi D, Hatcher D. Specialty Imaging: Temporomandibular Joint. ISBN: 978-0-323-37704-1. 2016 18. Salsench J. Dual bite demonstrated by kinesiography: a case report. Quintessence Int. 26(7):471-77, 1995 19. Ikeda K. TMJ 1st Orthodontics: Concepts, Mechanics, and Stability. Topnotch Kikaku Ltd: Japan, 2014 20. Katyal V, Pamula Y, Daynes CN, Martin J, Dreyer CW, et al. (2013) Craniofacial and upper airway morphology in pediatric sleep-disordered breathing and changes in quality of life with rapid maxillary expansion. Am J Orthod Dentofacial Orthop 144: 860-871. 21. MG Fjeld, LZ Arvidsson, H-J Smith. Relationship between disease course in the temporomandibular joints and man-
31. S.F. Dachi, F.V. Howell. A survey of 3,874 routine fullmonth radiographs. II. A study of impacted teeth Oral Surg Oral Med Oral Pathol, 14 (1961), pp. 1165–1169 32. P.S. Grover, L. Lorton The incidence of unerupted permanent teeth and related clinical cases Oral Surg Oral Med Oral Pathol, 59 (1985), pp. 420–425 33. Bedoya MM, Park JH. A review of the diagnosis and management of impacted maxillary canines. J Am Dent Assoc 2009; 140:1485–93. 34. Manne R, Gandikota C, Juvvadi SR, Rama HR, Anche S. Impacted canines: etiology, diagnosis, and orthodontic management. J Pharm Bioallied Sci 2012; 4: S234–8. doi: 10.4103/0975-7406.100216
35. H. Jacoby The etiology of maxillary canine impactions Am J Orthod, 84 (1983), pp. 125–132 36. S. Peck, L. Peck, M. Kataja The palatally displaced canine as a dental anomaly of genetic origin Angle Orthod, 64 (1994), pp. 249–256 37. R.G. Oliver, J.E. Mannion, J.M. Robinson Morphology of the maxillary lateral incisor in cases of unilateral impaction of the maxillary canine Br J Orthod, 16 (1989), pp. 9–16 38. Eslami, Ehsan ; Barkhordar, Hamid ; Abramovitch, Kenneth ; Kim, Jessica ; Masoud, Mohamed I. Cone-beam computed tomography vs conventional radiography in visualization of maxillary impacted-canine localization: A systematic review of comparative studies American Journal of Orthodontics & Dentofacial Orthopedics, February 2017, Vol.151(2), pp.248-258 39. Haney E, Gansky SA, Lee JS, Johnson E, Maki K, Miller AJ: Comparative analysis of traditional radiographs and conebeam computed tomography volumetric images in the diagnosis and treatment planning of maxillary impacted canines 40. Botticelli S, Verna C, Cattaneo PM, Heidmann J, Melsen B. Two- versus three-dimensional imaging in subjects with unerupted maxillary canines. Eur J Orthod 2011; 33: 344–9. doi: 10.1093/ejo/cjq102 41. Katheria BC, Kau CH, Tate R, Chen JW, English J, Bouquot J. Effectiveness of impacted and supernumerary tooth diagnosis from traditional radiography versus cone beam computed tomography. Pediatr Dent 2010; 32: 304–9. 42. Wriedt S, Jaklin J, Al-Nawas B, Wehrbein H (2011) Impacted upper canines: examination and treatment proposal base don 3D versus 2D diagnosis. J Orofac Orhop 73: 28–40 43. Bjerklin K, Ericson S. How a computerized tomography examination changed the treatment plans of 80 children with retained and ectopically positioned maxillary canines. Angle Orthod 2006;76(1):43-51. 44. J Orthod Sci. 2014 Apr-Jun; 3(2): 34–40. doi: 10.4103/22780203.132911 PMCID: PMC4077106 The effect of using CBCT in the diagnosis of canine impaction and its impact on the orthodontic treatment outcome Ali Alqerban, Reinhilde Jacobs,1 Pieter-Jan van Keirsbilck, Medhat Aly, Steven Swinnen, Steffen Fieuws,2 and Guy Willems 45. Ericson S, Kurol J (2000) Resorption of incisors after ectopic eruption of maxillary canines: a CT study. Angle Orthod 70:415–423 46. Z. Fuss, I. Tsesis, S. Lin Root resorption—diagnosis, classification and treatment choices based on stimulation factors Dent Traumatol, 19 (2003), pp. 175–182 47. M.E. Follin, A.M. Lindvall Detection of lingual root resorptions in the intraoral radiographs. An experimental study Swed Dent J, 29 (2005), pp. 35–42 48. F.M. Andreasen, I. Sewerin, U. Mandel, J.O. Andreasen Radiographic assessment of simulated root resorption cavities Endod Dent Traumatol, 3 (1987), pp. 21–27 49. V.P. Westphalen, I. Gomes de Moraes, F.H. Westphalen, W.D.
Martins, P.H. Souza Conventional and digital radiographic methods in the detection of simulated external root resorptions: a comparative study Dentomaxillofac Radiol, 33. 2004 50. Alqerban A, Jacobs R, Lambrechts P, Loozen G, Willems G. Root resorption of the maxillary lateral incisor caused by impacted canine: a literature review. Clin Oral Investig 2009; 13: 247–55. doi: 10.1007/s00784-009-0262-8S. Patel, A. Dawood, R. Wilson, K. Horner, F. Mannocci The detection and management of root resorption lesions using intraoral radiography and cone beam computed tomography—an in vivo investigation Int Endod J, 42 (2009) 51. Alqerban, R. Jacobs, S. Fieuws, G. Willems Comparison of two cone beam computed tomographic systems versus panoramic imaging for localization of impacted maxillary canines and detection of root resorption Eur J Orthod, 33 (2011) 52. Durack C, Patel S, Davies J, Wilson R, Mannocci F. Diagnostic accuracy of small volume cone beam computed tomography and intraoral periapical radiography for the detection of simulated external inflammatory root resorption. Int Endodont J 2011; 44: 136–47. doi: 10.1111/j.13652591.2010.01819. 53. Ren H, Chen J, Deng F, Zheng L, Liu X, Dong Y. Comparison of cone-beam computed tomography and periapical radiography for detecting simulated apical root resorption. Angle Orthod 2013; 83: 189–95. doi: 10.2319/050512-372.1 54. Wriedt, S., Jaklin, J., Al-Nawas, B. et al. J Orofac Orthop (2012) 73: 28. doi:10.1007/s00056-011-0058-8 55. Ghaeminia, H. ; Meijer, G.J. ; Soehardi, A. ; Borstlap, W.A. ; Mulder, J. ; Vlijmen, O.J.C. ; Bergé, S.J. ; Maal, T.J.J. The use of cone beam CT for the removal of wisdom teeth changes the surgical approach compared with panoramic radiography: a pilot study. International Journal of Oral & Maxillofacial Surgery, 2011, Vol.40(8), pp.834-839 56. J.P. Rood, B.A. Shehab. The radiological prediction of inferior alveolar nerve injury during third molar surgery. Br J Oral Maxillofac Surg, 28 (1990), pp. 20–25 57. Schlicher W, Nielsen I, Huang JC, Maki K, Hatcher DC, Miller AJ. Consistency and precision of landmark identification in three-dimensional cone beam computed tomography scans. Eur J Orthod. 2012 Jun;34(3):263-75. doi: 10.1093/ejo/ cjq144.Epub 2011 Mar 8. PubMed PMID: 21385857. 58. Stratemann SA, Huang JC, Maki K, Miller AJ, Hatcher DC. Comparison of cone beam computed tomography imaging with physical measures. Dentomaxillofac Radiol. 2008 Feb;37(2):80-93. doi: 10.1259/dmfr/31349994. PubMed PMID: 18239035. 59. Adams GL, Gansky SA, Miller AJ, Harrell WE Jr, Hatcher DC. Comparison between traditional 2-dimensional cephalometry and a 3-dimensional approach on human dry skulls. Am J Orthod Dentofacial Orthop. 2004 Oct;126(4):397-409. PubMed PMID: 15470343. 60. J.B. Ludlow, C. Walker. Assessment of phantom dosimetry and image quality of i-CAT FLX cone-beam computed tomography. Am J Orthod Dentofacial Orthop, 144 (2013), pp. 802–817
AMERICAN BOARD OF ORTHODONTICS REPORT Dr. Chun-Hsi Chung
n September of 2016, the ABO conducted a Clinical Exam and a total of 94 examinees were certified or recertified. In February of 2017, a total of 94 examinees were certified or recertified. The next ABO Clinical Exam is scheduled for September 25-29, 2017 in St. Louis. The Board continues to respond to our specialty’s changing environment in numerous ways. Beginning in January 2017, the ABO is offering options for Certification Renewal. Option 1 involves submission of one patient case by mail, and Option 2 now allows you to prepare on-line treatment plans for two board cases provided by the ABO. Please visit www.AmericanBoardOrtho.com for additional information. In April of 2017, the ABO Written Examination was administered to 391 candidates at Pearson-Vue Testing Centers across the United States and Canada. The next Written Examination is scheduled for April 10-13, 2018. Congratulations to the following individuals who were recognized by the ABO for their extensive contributions to the specialty of orthodontics during the 2017 AAO Annual Session in San Diego, CA. • Dr. Sheldon Peck - Albert H. Ketcham Memorial Award • Dr. Andrew J. Haas - Dale B. Wade Award of Excellence in Orthodontics • Dr. Michael L. Riolo - Earl E. and Wilma S. Shepard Distinguished Service Award • Dr. Deborah E. Priestap - O.B. Vaughan Special Recognition Award If you attended the 2017 AAO Annual Session, we hope you had the opportunity to stop by the ABO
Case Display Room at the Convention Center to view successful cases from the past year’s ABO Clinical Examinations. In addition, an ABO booth was located outside of the Exhibit Hall, showcasing the ABO educational materials available to board certified orthodontists. The ABO also hosted an Advocacy Workshop were available resources and answers to frequently asked questions were presented. As a reminder, the ABO offers educational materials to board certified orthodontists on the ABO website. Printed materials may be ordered on-line or you may print your own by downloading PDF’s directly at no charge. When placing an on-line order, you will need your ABO ID number and password. The ABO is excited to again welcome orthodontic program department chairs, program directors and ABO-appointed advocates to the 2017 ABO Educator’s Symposium “Intelligently Adapting to Change”, honoring Dr. Thomas Cangialosi. The Symposium will be held on November 17-18, 2017 in St. Louis, Missouri. Together we will collaborate to guide the ABO to continue to evolve and adapt to the constant changes in our specialty. The ABO and the College continue to work together to support orthodontic programs in their preparation for the clinical exam through our advocacy program. To date, all orthodontic programs have at least one advocate assigned to each school. The ABO appreciates the College offering courses for examinees to prepare for the clinical exam during constituency meetings and at the AAO Annual Session. I look forward to our continued collegial and strong relationship with the College. If you have any questions regarding the American Board of Orthodontics please contact me at Chung@AmericanBoardOrtho.com.
NEW ABO PRESIDENT By Chun-Hsi Chung, 2017-2018 President
The American Board of Orthodontics (ABO) installed Dr. Chun-Hsi Chung of Bryn Mawr, Pennsylvania, as president April 25th during the ABO President’s Dinner. This event was held in conjunction with the 2017 Annual Session of the American Association of Orthodontists (AAO) in San Diego, California. The other officers of the ABO are Dr. Larry Tadlock of Colleyville, Texas, president-elect, and Dr. Nicholas Barone of Lincoln, Rhode Island, secretary/treasurer. Dr. Steven Dugoni of South San Francisco, California, is the immediate past president. During his tenure as an ABO director, Dr. Chung has represented the Middle Atlantic Society of Orthodontists. He currently serves as a member of the ABO’s Executive Committee, and the ABO’s liaison to the American Association of Orthodontists (AAO), the College of Diplomates of the ABO (CDABO), the American Journal of Orthodontics and Dentofacial Orthopedics (AJODO), the Council on Dental Education and Licensure (CDEL), the Graduate Orthodontic Residents Program (GORP), the World Federation of Orthodontists (WFO), and the Society of Educators (SOE). In addition, Dr. Chung is serving on the planning committee for the 2018 AAO Annual Session, which will be held in Washington, D.C. He also serves as the co-chair of the Doctors’ Program for the 2018 AAO Annual Session. Dr. Chung is the Chauncey M. F. Egel Endowed Chair and Associate Professor of the Department of Orthodontics at the University of Pennsylvania School of Dental Medicine. He is a member of the Edward H. Angle Society of Orthodontists and is a consultant to the Commission on Dental Accreditation (CODA). Dr. Chung’s primary research interests include craniofacial growth and development, dentitional develop-
ment, rapid palatal expansion, orthodontic treatment for young children and adults. He has many papers published in the American Journal of Orthodontics and Dentofacial Orthopedics, European Journal of Orthodontics, Angle Orthodontist, Journal of Clinical Orthodontics, Seminars in Orthodontics, Seminars in Orthodontics, International Journal of Adult Orthodontics and Orthognathic Surgery, Journal of Craniofacial Genetics and Developmental Biology, and Calcified Tissue International. Dr. Chung has lectured extensively nationally and internationally. In addition, he has received numerous awards and honors for his contribution to orthodontic profession and education. Dr. Chung maintains his clinical practice at the Penn Dental Family Practice in Bryn Mawr, PA. “It has been a great honor for me to serve as the director of the American Board of Orthodontics for the last seven years. I have had the privilege to collaborate with a group of dedicated current and previous ABO directors to strive toward our goal, which is to elevate the quality of orthodontic care for the public. Through the years, the ABO certification process has continued to evolve. More recently, the environment of the orthodontic specialty has been rapidly changing, thus it is necessary for ABO to be responsive to the changes. For the coming year as president, I look forward to working closely with colleagues on how to respond intelligently to the environmental changes in terms of the certification process. I will focus more on promoting board certification for new orthodontic graduates and experienced practitioners. The goal is to have the majority of AAO members board certified in the near future.” Dr. Chung said.
College of Diplomates of the American Board of Orthodontics 401 N. Lindbergh Blvd St. Louis, MO 63141
Student Membership Application
Please type or print information Date: Student name for membership AAO Student Member Number (if applicable) Address City:
Home Phone: Cell Phone: Fax: E-Mail: Dental School
Year of Graduation
Year of Expected Graduation
Department Chair Where do you plan to practice upon graduation? When do you plan on taking the ABO Written Exam? When do you plan on taking your ICE (Initial Certification Exam)? Signature Please email or fax your completed application to TheCollege@aaortho.org or 314-993-6843
Your student membership begins when your completed application is received.
Disney’s Boardwalk Inn Orlando, FL
Friday, July 6 – July 10, 2018
Gaylord Opryland Resort & Convention Center Nashville, TN
Friday, July 12 – July 16, 2019 ©CDABO 2017
EVALUATING PROFESSIONAL ADVICE: 11 QUESTIONS TO ANSWER BEFORE YOU COMMIT Rich Arzaga, CFP, CCIM
rofessional advisors work in many fields and hold various titles, such as investment advisor, financial planner, accountant, estate planner, insurance agent, and stockbroker. Over the last few years, most professional advisors have seen their roles expand and now the lines among them have become greatly blurred. Today it is now commonplace to meet an insurance agent who is also registered as an investment advisor or a stockbroker who engages in the practice of estate planning. With so many potential professional investment advisors to choose from, the process can seem daunting. Remember, not all professional advisors are equal! Some advisors may say the same things as others, but when you investigate further you will discover significant differences. The following are 11 questions you should investigate when evaluating a potential financial advisor.
Question 1: What financial services do the advisors offer? It is important to first determine what services you are seeking: investment counseling, total financial planning, estate planning, and/or tax preparation. When you know that, you should investigate whether or not the advisors offer these services. This is important because most professional advisors do not offer a complete array of services. It is common for advisors either to have relationships with outside advisors who can address the areas not serviced or, if their firm is large enough, to have someone else in their firm handle separate services.
Question 2: Do the advisors offer customized portfolio solutions or more of a cookie cutter solution? Regardless of your financial objectives and constraints, some financial advisors only offer one or two approaches to managing wealth, specifically portfolio management. For instance, you may find advisors who build practically the same portfolio for all of their investors without taking into consideration their ability or willingness to tolerate risk. Most financial advisors realize that customized portfolios provide the best way to achieve investors’ goals and objectives. However, be cautious and ask how tailored their portfolio solutions are.
Question 3: What are the specific qualifications of the advisors? What education do the investment advisors have? Bachelor’s? Master’s? Find out what their degree is
in: finance, accounting, marketing, economics, literature? You would be surprised at the number of practicing advisors who have either no bachelor’s degree or a degree in a field unrelated to finance and investing. You should also investigate whether or not the advisors have earned professional designations, such as CPA (Certified Public Accountant), CFP (Certified Financial Planner), CFA (Chartered Financial Analyst), or ChFC (Chartered Financial Consultant). Having a designation illustrates commitment and very specialized knowledge that can separate the top advisors from the rest of the pack.
Question 4: How much and of what type of experience do the advisors have? You should find out how long the advisors have been in practice and how long they have been in their present role. A follow-up question could address the advisors’ specific work experience. Also, do not be fooled by age. Many advisors who enter the business late in their careers have as much (or as little) to offer as someone straight out of college.
Question 5: How ethical and trustworthy are the advisors?
Question 8: What are the fees and by what method are the advisors paid?
This question is obviously very subjective and not always easy to answer when you first meet potential advisors. A good way to approach this question is to investigate their backgrounds, specifically whether a regulatory organization or private association to which they belong has publicly disciplined them. To check on an advisor’s regulatory records, you should contact FINRA (Financial Industry Regulatory Authority) or any association the advisor may be a member of, such as the Certified Financial Planning Board of Standards (www.CFP.net) or the CFA Insti�tute (www.CFAInstitute.org).
There are many ways an advisor can be compensated: commission, a percentage of a portfolio’s market value (asset-sized fee), hourly fees, fees for individual services performed, or any combination. There is no right or wrong fee structure. The best fee structure is what makes sense and is the best fit for you. Most advisors will be able to provide the investor with a written document outlining their fees. If an advisor cannot provide this, move on. Don’t be afraid to ask about fees up front.
Question 6: What are the advisors’ investment process and investment philosophy?
Question 9: What is the long-term performance or track record of the advisors?
Some advisors have been known to “wing it” when designing portfolios because they either have no philosophy or fail to adopt one. You should ensure that advisors you are considering incorporate asset allocation into their investment philosophy and apply it to their portfolio management process. Also, you should consider investigating whether or not advisors adopt some sort of plan for building an optimal portfolio. Asking questions at this point is very wise and will minimize issues going forward.
The vast majority of advisors can provide you with some sort of performance composite for you to review. When reviewing performance information, be sure to learn which benchmark(s) are employed (such as the S&P 500), how well the advisor performed against the benchmark(s), the consistency of performance over long periods of time, the volatility of performance [especially in relation to the benchmark(s)], the growth of assets under management, and the statement of whether or not the performance conforms to CFA Institute standards. If any of these items are not voluntarily provided, ask the advisor to provide them. If the performance was not created according to CFA Institute standards, ask why. Performance is suspect when the advisor has not conformed to any standards, especially the tough CFA Institute standards. The CFA Institute is the organization that oversees the Chartered Financial Analyst (CFA) designation.
Question 7: What is the advisors’ tax management philosophy? Advisors approach the tax management issue from different viewpoints. Some advisors underemphasize tax management while others overemphasize it. Specifically, ask about the general degree of turnover, how they incorporate tax management into the rebalancing phase, whether or not they can incorporate tax losses or gains generated outside of the portfolio, and how they approach the issues of loss-harvesting and exchange strategies.
Question 10: What is the profile of their typical investor?
Your goal here is to find out whether or not the advisor under investigation is knowledgeable about your objectives, constraints, problems, and solutions. Some advisors work with everyone, thus are jacks-of-all-trades, whereas others work only with specialized groups of people, such as affluent investors; thus they are exposed day in and day out to the issues faced by that group and how best to deliver a targeted solution.
ally after the first meeting you will know if there is a fit or not. Is the advisor more serious or humorous? Is the advisor intense or low-key? Is the advisor more professional or down-to-earth? Does he or she play golf? Did a friend refer you? Are your interests similar? Questions like these will help you determine if your personalities mesh, which makes dealing with each other so much easier.
Knowing the typical clientele gives you a good idea of the type of problems and solutions the advisor is most experienced with. Since some people require very specific financial solutions, knowing the typical investor will help you to discover whether or not that advisor can effectively work with you.
In addition to the questions presented, another good way to evaluate an investment advisor is to review what is called Form ADV Part II. This form is required by the Securities and Exchange Commission (SEC) or the state of domicile of all investment advisors. In addition, all investment advisors are required to provide this document to prospects before any services are provided. If you are not given one, be sure to ask for it.
Question 11: Is there a personality fit?
Disclaimer: Excerpted from Understanding Asset Allocation by Scott Frush. Copyright © 2007 by The McGraw-Hill Companies, Inc. All rights reserved.
The last question deals with whether or not you can work with the advisor. This question is more intuitive-oriented rather than objective-oriented. Usu-
Editor’s Note: Mr. Arzaga will be presenting a supplemental lecture for spouses and staff on Saturday, July 8, 2017.
Save the Date! 39th Annual Meeting "Controversies: Stability of the End Result"
July 7-11, 2017 Resort at Squaw Creek, Lake Tahoe, CA
Phone: (888) 217-2988