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SAO LEADERSHIP President Dr Jeri Stull Fort Thomas, KY President-Elect Dr Sims Tompkins Columbia, SC Secretary-Treasurer Dr Eric Nease Spartanburg, SC

SAO NEWS IN THIS ISSUE

Message from the President – Jeri Stull ............ Page 2 Executive Committee Biographical Sketches – ............ Page 3 Stull, Tompkins, Nease, Dusek, Sema, Faber

First Senior Director Dr Mark W. Dusek Savannah, GA

THANK YOU – Dr Inman ............ Page 4-5 Message from the SAO Trustee – ............ Page 6 Richard Williams

Second Senior Director Dr Debbie Sema Birmingham, AL Third Senior Director Dr Beth Faber Tidewater Region, VA Past President Dr Anthony W. Savage Virginia Beach, VA

AAO Trustee at Large – Alex Thomas ............ Page 6 Sharon Hunt – 2020 AAO Outstanding ............ Page 7 Contribution Award Oren Oliver Distinguished Service Award – ............ Page 8 Bob Calcote Faculty Award – Lina Sharab ............ Page 9

AAO Trustee Dr Richard Williams Southaven, MS AAO Trustee at Large Dr Alexandra Thomas Spartanburg, SC Speaker, AAO House of Delegates Dr Jeff Rickabaugh Winston-Salem, NC Director, The American Board of Orthodontics Dr Tim Trulove Montgomery, AL

SAO CONTACT INFORMATION Ms. Heather Hunt Executive Director 32 Lenox Pointe Atlanta, GA 30324 Phone: (404) 261-5528 Fax: (844) 214-1224 hhunt@saortho.org

How would You Treat This Patient? – ............ Page 10-13 Timothy Shaughnessy COVID-19 Education – Eladio DeLeon, Eser Tüfekçi ............ Page 13-15 SAO 2019 Leadership Report – Green Team ............ Page 15-18 SAO 2019 Leadership Project – Blue Team ............ Page 18-20 SAO 2019 Leadership Project – Orange Team ............ Page 20-22 Research Report: West Virginia University – ............ Page 23-25 Identifying the Esthetically Optimal AP Position of Maxillary Incisors in Caucasian Females Council on Scientific Affairs ............ Page 26

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President’s Message Jeri Stull

SAO – Nashville Tennessee October 15-17, 2020

We are still on for Nashville!

2020–A Perfect Vision??? This clever tag line… I developed this while brainstorming soon after our Executive Director, Heather Hunt, accomplished a major success landing the Omni Hotel in Nashville in late 2015. Now it seems less clever and more ironic. The past three months have been a crazy, alternate universe for our country and the world that no one could have predicted. As I am writing this, most of us have been back to work at some capacity for over a month. It feels great to see our patients! I love my new scrubs but I have a love / hate relationship with my face shield… I can’t believe what it looks like at the end of the day. The 2020 SAO Meeting has NOT been cancelled. Life is better smiling with friends and colleagues at the 2020 Nashville Meeting… even if we are still wearing masks! The 2020 Meeting Team has been hard at work for years to achieve an amazing meeting experience. We have booked engaging speakers, and planned exciting

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social and networking events. A special thanks to my Meeting Chair, Dr Debbie Sema, and our Executive Director, Heather Hunt, because to say that it has been tumultuous is an understatement. Some Constituencies have already cancelled their fall meetings due to travel outside of the country or areas that still haven’t fully reopened at this time. With uncertainty, even in the South, about what the fall will look like for schools, meetings, sports, and other large gatherings we have pivoted and are continuing to plan the live meeting but we are also investigating a virtual platform. Please respond to the SAO Meeting Survey, because this will give us great information for our final planning. If you did not receive the survey, reach out to Heather (hhunt@saortho.org) or me (jeristull@gmail.com) and we will be glad to forward you a link or get your feedback verbally. At this time we are planning on opening registration late July or August. We are living in uncertain times, but I am certain that if we can all meet in Nashville for the 2020 SAO Fall Session… we will have a fantastic experience in Music City, and we will front the group as we “put our band back together”.


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Executive Committee

The Executive Committee of the SAO works very hard to manage the affairs of the SAO. Our Executive Committee is an energetic, committed group. The staff of the SAO News wants all members to know who are on our Executive Committee. Jeri Stull, President

Eric R. Nease, Secretary/Treasurer

Jeri Stull is the current President of the Southern Association of Orthodontists. She is in Orthodontic Practice in Fort Thomas and Florence, Kentucky. Her long history of service to the specialty includes terms on the SAO Executive Committee, AAO Delegate, KAO President and KAO Director. Dr Stull has also served on many AAO Committees and Task Forces including: Task Force to Study Funding for the Consumer Awareness Program, Governance Study, Governance Stakeholders Committee, Task Force on Women Orthodontists, and Special Committee on Women Orthodontists. She is a current member of the SAO-SWAO Ad Hoc Committee that is investigating paths for merger of the two associations. She believes that the only way to preserve our profession is to engage our new and younger members and increase diversity in leadership that will reflect the membership. In her leisure time, Dr Stull enjoys traveling, golf, live music, and sporting events with her fiancé, Dr Dallas Margeson and her two sons, Evan and Mason.

Eric R. Nease grew up in Parrottsville, TN, third oldest town in the state, and one of the smallest. Eric is a true product of the Tennessee public school system, receiving all of his education in Tennessee, from Parrottsville Elementary School, to Cocke County High School, to the University of Tennessee, and finally the University of Tennessee College of Dentistry. Eric earned both his DDS and MDS in Orthodontics from the UT College of Dentistry. He is married to Melody, a 5th grade teacher. They have 4 adult children (Sydney, Cameron, Ansley, and Reagan) in various stages of higher education that keep them both grounded. Eric is a lifelong Tennessee Volunteer fan and attends as many games as he can, both at home and on the road. He commented, “I’ve seen both the good –1998 National Championship – and the bad... have you seen them lose to Vandy recently?”. He also enjoys golfing, hunting, and the occasional trip to the ski slopes. “Orthodontics was my dream job as a child, and it continues to be that today. There’s nothing else I’d rather do! Greatest profession in the world. Shhhhh…”.

Richard Sims Tompkins, President Elect

Mark Dusek, First Senior Director

Sims Tompkins is a native of Columbia, SC. After graduating from Cardinal Newman High School, he received a BS degree in Microbiology from Clemson University, a DMD degree from the Medical University of South Carolina, School of Dental Medicine, and a Master’s degree in Orthodontics from Temple University, School of Dentistry. Dr Tompkins joined his father’s orthodontic practice in the fall of 1988 and became involved with dental sleep medicine in 1991.

Mark Dusek practices in Savannah, Georgia with his partners Drs Tom Broderick and Chris DeLeon. He is involved in organized dentistry both with the ADA and the AAO. He is married to Carol Dusek and has three children; Sarah, Philip, and Stephen. While not practicing, Dr Dusek enjoys reading, swimming, riding his bike, and playing golf.

Debbie Sema, Second Senior Director

Debbie Sema is a native of Mobile, Alabama, and grew up enjoying time with her family on the Alabama coast. She is a graduate of the University of Alabama at Birmingham School of Dentistry and orthodontic residency program. Dr Sema has practiced orthodontics in the Birmingham area for over twenty years. She loves serving her community through her practice and volunteer organizations and enjoys time at the lake with her friends, family, and precious black Lab, Bella.

Dr Tompkins is a Diplomate of both the American Board of Orthodontics and the American Board of Dental Sleep Medicine. He has been and continues to be active in a variety of professional organizations. He is a member of the American Dental Association, the American Association of Orthodontists and the American Association of Dental Sleep Medicine. He has been on the Board and served as President of the Greater Columbia Dental Association. Dr Tompkins is on the Executive Committee for the Southern Association of Orthodontists and is currently President-elect. He has served on the Dental Advisory Board of the Department of Allied Health at Midlands Technical College and he is a member of the South Carolina Center for Cleft Palate and Craniofacial Disorders. He volunteers his time and service several times a year to the Children’s Dental Clinic of Richland and Lexington counties and has served as a member of their Advisory Committee.

Beth Faber, Third Senior Director

Beth Faber is a practicing orthodontist in rural Tidewater Virginia. She earned her dental degree at the Medical College of Virginia and completed her MS certification in Orthodontics at the University of Detroit. Dr Faber has served as the VAO president and as the Virginia delegate to the House of Delegates.

Dr Tompkins is married to his wife of 35 years, Libby, and they have three adult children and one grandson. His oldest son is currently in his orthodontic residency and plans to join his father’s practice when he returns – a practice that was established by his grandfather in January 1966.

Beth is an active member of Fairmount Christian Church and has served on two mission trips to Niger, Africa. She and her husband, Frank, are passionate about their family including ten grandchildren, their faith, and patients.

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Thank You, Dr Inman... Gary, there have been two times that you

have been an orthodontic quarterback during unprecedented events. First, in 2015 you stepped up on very short notice to become the SAO’s Trustee on the AAO’s BOT. You quarterbacked the Southern team at that point. You learned quickly and became a vital and contributing member of the AAO’s Board of Trustees. You proved that even an old Kentucky boy could learn very fast and lead at a very quick pace. Second, you quarterbacked the AAO and its Board of Trustees during our very difficult COVID times. You made some difficult decisions; decisions that you didn’t like and I didn’t like, but we knew that they had to be made. Our Annual Session Planning Committee had planned, for years, for an AAO annual session in Atlanta, the first time for AAO to go there since 1982. We had to cancel. That was a tough decision but it was the right decision. You quarterbacked your team during this time of stress and trouble. One real advantage to leadership is that leaders get to make great friendships. I think back to the time that you and I first became friends. We were on the Southern Association Board. I represented Tennessee and you represented Kentucky. We became instant friends and have stayed that way for many, many years. I think about our ski trips, the down hill ski club where we had a great time with your three sons and the golf trips to Scotland where we played St. Andrews. Those were great times. The dinners, the laughs, the camaraderie, being with our wives and sharing times together have been so memorable. During all these gatherings, I got to know the real

Gary Inman: the Gary Inman who loves our specialty; the Gary Inman who loves life; the Gary Inman who loves his family, his wife, his three boys, and his grandchildren; the Gary Inman who has strong spiritual beliefs. Gary, I regret that you did not have the experience that every AAO President and every Annual Session Planning Committee have had by being “live” at AAO’s Atlanta meeting. But Gary, you will always be remembered as the AAO President who served in extremely difficult times; as the AAO President who provided exemplary leadership, the right leadership at the right time; leadership that helped AAO and its members get through these tough times. Gary, congratulations on a job well done. I want to be the first to welcome you to the AAO Past President’s “club”, a very distinguished group of individuals. You will enjoy the title of Past President! Thanks, Gary. Thanks for all you have done. I love you.

our first Virtual AAO Session 2020. It was an astonishing success. We had over 11,000 people register for the event with 9000+ actual attendees. Although this was not the event any of us had hoped for, it was an amazing testimony to Gary’s leadership and ability to adapt.

DeWayne McCamish

Gary has been relentless in his desire to move the AAO ahead. The BOT has referred to him as the “President of Change” for his desire and commitment to bring diversity to the BOT. As many of you are aware from the news release of June 6, 2020, there are now two additional at-large Trustees seated and ready to begin a term of up to three years on the Board. Those two individuals are Alex Thomas and Dale Anne Featheringham. Alex practices in South Carolina with Eric Nease and is a recent graduate of the University of Michigan. Dale Anne is from Ohio. She will provide valuable insight as we move ahead. Gary’s dream has become reality! So kudos Gary and THANK YOU!

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extend my heartfelt gratitude to Gary Inman, now immediate past president of the AAO. Gary has been the model of “cool under pressure” for these last few months and has guided the AAO and the Board of Trustees with a steady hand. He has exhibited sound and reasonable judgement along the way. With the onset of Covid 19, the AAO was faced with the need to be nimble (to borrow a term from Sharon Hunt) and make quick decisions in order to cancel Atlanta 2020. Gary, along with AAO staff, guided us into a good decision to not only cancel, but to innovate to the circumstances and create

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Richard Williams


June 2020

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r Inman, thank you so much for a wonderful year. It’s not exactly what we expected since we did have a little virus that came our way but as they say, “The virus is contagious but so is kindness,” and your kindness has been contagious to everyone. You have been so thoughtful, you have been the calm in the storm, you have reached out to collaborate with others, you have been great with the staff, you have a wonderful Board behind you and all I can say is, thank you so much from all of us at AAO.

Lynne Thomas Gordon

CEO, American Association of Orthodontists

“If your actions inspire others to dream more, learn more, do more, and become more, you are a leader.” John Quincy Adams

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he past several years have been difficult ones for the AAO. There have been many challenges: legislative challenges, challenges from membership, challenges from outside entities who are marketing orthodontic services without the involvement of a doctor, and most recently, the pandemic. During these difficult years, Gary Inman has been a “leader’s leader”. The ultimate leadership test came with the COVID pandemic. All the plans for the AAO Annual Session in Atlanta had been made; everything was in place. Gary had to make the difficult but necessary decision to ask the Board of Trustees to cancel the meeting. This could have been a time of great despair for everyone involved with AAO - members, employees and friends of AAO around the world. Yet, Gary, with innovative thinking and calm leadership, along with the help of AAO staff, organized a “miracle” - a virtual meeting with over 11,000 registrants that has received rave reviews! Gary Inman’s vision and his

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leadership were instrumental in turning a bad situation into a very good situation. He inspired the Board Of Trustees, AAO employees and AAO membership to “dream more, learn more, do more and become more”! The mark of a true leader is how that person handles adversity. The leader who handles adversity with class, innovative ideas, and determination is the leader who is remembered. Gary Inman is truly a class act and a leader’s leader who will forever be remembered for his kind, considerate, empathetic and inspirational leadership. THANK YOU, Dr Inman. James Vaden


SAO Trustee Update

Richard Williams

Greetings to my fellow Southerners

It has been a rare time for the SAO. We have enjoyed having three members involved with the AAO Board of Trustees. Gary, President, and Jeff Rickabaugh, Speaker of the AAO House of Delegates, have exhibited the same passion and leadership we enjoyed from them while both served the SAO. Both are visionary and both provide guidance with dignity and resolve in these challenging times. It has been a true privilege to walk this path with them as we strive to improve the AAO and its relevance to our members. I will attempt to give you some insight into two of the pressing topics of the day: Advocacy and the CAP program. Advocacy has seen a shift in focus over the past few years to be inclusive of critical challenges at the state and local level. Our AAO legal team has experienced some change because Sean Murphy, our general counsel, left AAO to become the Executive Director of the Arizona Dental Association. Sean was instrumental in coordinating our strategies and guided our staff as we sought to influence state dental boards to protect our patients and improve their orthodontic health. Trey Lawrence and Andrew Wiltsch are our staff attorneys. Gianna Hartwig is our legal assistant. Gianna monitors state board activity and informs our attorneys in the event there are items coming before Boards with which we need to be involved. To date, we have helped over 40 dental boards by providing language for regulations and proposed legislation that is critical for patient protection. I encourage you to become proactive in your state by attending State Dental Board meetings and by voicing your concerns when given the opportunity. I do not remember who said it, but when it comes to advocacy, your choices are to be AT the table or ON THE TABLE!

There have been some recent successes at the federal level. We have seen a permanent repeal of the medical device tax as well as a repeal of the “Cadillac Tax” on premium health plans. We have also received a copy of a letter sent by nine Congressmen that asks for the FTC and FDA to further investigate DTC orthodontics. Kathy DiPrimo is a member of our wonderful St. Louis staff who has assisted in these efforts. All of this could not be possible without your support of AAOPAC. Please give when given the opportunity. Advocacy day in Washington, D.C. was on February 25 and 26. These days provided the opportunity for us to take our concerns on a number of issues, including student debt, to Capitol Hill. Please go to the AAO member website under the legal and advocacy tab if you are interested in a timeline of activity. You may want to peruse the AAO website for information regarding the Consumer Awareness Program. I have been amazed at the exponential increase in the impact of this program over the past year. The AAO Team and COC seem to be always moving strategy ahead and doing it in a way that provides maximum impact for the dollars we are deploying. If you do not log in to the member website often, I encourage you to start to do so on a regular basis. Last year the locater service had over 1 million contacts from people who sought to find YOU! When you log into the website, a pop up will tell you how many times your name has been furnished to date. Please make sure your demographic information is correct so that you can have patients in your chair from this valuable service. By the numbers, 1.2 billion ad views last year pushed 5.9 million users to our website. Of late, we have started a campaign which utilizes “influencers” to affect our target audience. It was reported to us at the Leadership Development Conference that 1 million moms were impacted in TWO DAYS by our message. Please help us grow our impact by following on social media and sharing whenever possible. There is a large body of material you can access for use on your sites if you desire. Most recently, our creative department has launched the “Happy Mouth Smiles” series. It is quite catchy and I am certain you will enjoy how we are moving our message forward. Our AAO is working for you and I am humbled and proud to be part of the team. Thank you for the opportunity to serve!

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Announcing the recent appointment of our very own SAO member to the AAO Board of Trustees!

AAO Trustee at Large Dr Alex Thomas

Dr Alexandra “Alex” Thomas is a Southern lady, born and raised. Atlanta was home for her first 16 years. She then moved to a small town in northern Virginia where she graduated from high school. From the time she could crawl, she has been an equine and animal enthusiast. The passion inspired her to major in Animal and Veterinary Science at Clemson University. She minored in business administration thanks to her dad who sparked a love for business. It was not until the spring of her senior year (she had been accepted to Veterinary Medicine College.) that some soul searching led her to explore other professions. A visit to her dentist in Clemson piqued her interest in dentistry. She shadowed a semester at his office and the rest is history. Dr Thomas received her dental degree at the Medical University of South Carolina where she graduated at the top of her dental school class for clinical excellence and was number two overall. In 2019 she completed her residency in orthodontics at the University of Michigan. She moved back to her Southern heritage and joined Nease (SAO Secretary/Treasurer) and Higgenbotham Orthodontics in Spartanburg, South Carolina. Alex and her husband Zack have two wonderful four-legged kids, a black Lab, Belle, and a beagle, Beau. Raised in a family of girls, she was her dad’s “boy” and shares his love of the outdoors. Dr Thomas and her family love horses, shooting sporting clays, bird hunting, any thing that has to do with fitness and a little fine dining along the way. She and Zack love the South and being close to their family, their church, and their community. Alex and Zack are also looking forward to diving back into Clemson athletics! Go Tigers!


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Sharon Hunt

2020 AAO Outstanding Contribution Award Recipient

At its virtual Annual Session, the American Association of Orthodontists honored Sharon Hunt posthumously with the 2020 AAO Outstanding Contribution Award.

Sharon Hunt was a leader’s leader. Outside of orthodontics, she served the Georgia Society of Association Executives as its 2003 President. She was also active in starting a Leadership Academy for this organization. In 2014 GSAE honored Sharon by renaming their ‘Emerging Leader Award’ to the ‘Sharon Hunt Emerging Leader Award’. She was a Senior Examiner for the Malcolm Baldrige Award of Excellence from 2008-2014. She was the 2015-2017 Chair of the Administrative Council of Embry Hills United Methodist Church. During this time, she initiated many consent agendas and strategic discussions for the Administrative Council of the church. She also served as Chair of the Finance Committee of Embry Hills as well as secretary of her condominium association.

Ms. Hunt was a transformative leader who had a vision. The criteria for this award was designed to recognize a person like Sharon. The Southern Association of Orthodontists is very pleased that its beloved former Executive Director was honored in this manner.

Sharon served the SAO, AAO, and the specialty of orthodontics with passion, intelligence and dedication. She became the SAO Executive Director in January 1996 and served until October 2014 when she retired. During those years, she was responsible for many innovative programs. Sharon developed and executed a Futures Study which was shared throughout the orthodontic community. She took the initiative to complete this Futures Study and interviewed people in all phases of orthodontics in order to predict future trends in the specialty. The results of this study have been used by both the SAO and the AAO to make proactive changes to improve member services and benefits. In 2007 she designed and launched the SAO Leadership Program. A total of 99 SAO members have completed this program. Sharon served on the AAO constituent/component Task Force in 2016-2017 and served the Southwestern Society of Orthodontists as a Director of Finance and Delegation.

Sharon was a true servant leader who transformed the lives of those she touched. She was dearly loved by all SAO members, by her fellow church members, her bridge group, her garden club, and all with whom she came into contact. She will forever have a fond spot in the hearts of the many she touched on her life’s journey. The SAO was blessed to have had Sharon in its midst for so many years. The membership of the SAO was very excited to see her awarded the AAO Outstanding Contribution Award was our own Sharon Hunt.

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Bob Calcote

Oren Oliver Distinguished Service Award

“It was my great pleasure at the SAO Annual Meeting in Orlando this past November to present the 2019 Oren Oliver Distinguished Service Award to Dr Robert D. Calcote.” Sims Tompkins

The criteria for receiving this honor include:

Dr Calcote is best known to his patients and friends as Dr Bob. He has been practicing the specialty of orthodontics for over thirty-five years. He has been president of the South Carolina Association of Orthodontists, has served as both a Director and a Delegate from South Carolina to the SAO, has served on the Executive Board of the SAO and was President of the SAO in 2011.

• The individual must be an orthodontist and an SAO member in good standing. • The achievements of the recipient rise above the ordinary and are far beyond the normal expectation of member leadership and service to the SAO.

Dr Bob, a native of Charleston, SC, joined his father’s orthodontic practice in 1985. His father, Dr Clarence Calcote, served as President of the SAO in 1981. Bob “grew up” in the orthodontic community and learned early on about service and giving back to the specialty that we all love. After his Presidency, Bob stepped up to help South Carolina and served as a Delegate for three years. This selfless devotion to the SAO and the orthodontic specialty goes to the heart of the Oren Oliver Award and I was honored to present this special award to my good friend and colleague Dr Bob Calcote.

• The achievements of the recipient go to the heart of and significantly advance the mission of the SAO. • The award itself will reflect not only honor on the individual, but reflect credit upon the Association.

Sims Tompkins (pictured below on the left with Bob Calcote)

• The recipient has consistently supported the SAO with attendance at Annual Meetings.

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Lina Sharab I University of Kentucky Faculty Award

Dr Lina Sharab is an assistant professor of orthodontics at the University of Kentucky. She is blessed with a mixture of multiple cultures that leave her open-minded and enthusiastic about learning new things every day. Her unique cultural background is the secret behind her love for education. Lina feels that the combination of education and orthodontics is the best formula for a fulfilling career.

Dr Sharab was raised to appreciate education and was inspired by dedicated educators in her family.

In her work at UK, Lina relishes the opportunity to learn from senior mentors and successful women in the field, enjoys communicating with adolescents and children during patient care, discussions with bright, young residents, and challenges of enthusiastic dental students to find their niche within the profession. She ends each day at home with a supportive husband and their three loving boys. Her husband, an Associate Professor in prosthodontics at UK and her boys are all fully supportive of Mom’s career, except her youngest, the six-year-old son who wants her to retire so they can play together more.

She received her dental degree in Syria and earned a Masters in Biomaterial Science from the State University of NY at Buffalo, School of Dental Medicine. She also received fellowship training in orthodontics in Buffalo from SUNY. She then pursued a Master of Science Degree and Certificate in Orthodontics at the University of Kentucky, College of Dentistry. In 2018 she joined the full-time faculty in the Division of Orthodontics at UK. There she teaches in both the pre-doctoral and graduate curriculum, participates in the orthodontic faculty practice, and pursues her research interests in various clinical topics. Dr Sharab is thankful for this rewarding profession. She has received multiple professional awards from local, regional, and national institutions for various professional activities, including teaching, research, and leadership awards. Her two most recent awards are from the AAO (Full-Time Faculty Fellowship Award); and from the Emerging Leaders Program of ADEA; (AAL Faculty of Color Tuition Scholarships for Professional Development Award). Other awards Dr Sharab has received in her young career: Thomas M. Graber Award of Special Merit (AAO), Center for Biomedical Research Excellence (UK), UK Center for the Enhancement of Learning and Teaching (UK), AAO Fellowship for Academy of Academic Leadership Sponsorship Program (AALSP).

Finally, Lina relishes the challenge of balancing her time and energy between her orthodontic family and her husband and three boys. She pursues fulfillment trying to make a difference in her professional and personal world and believes that education is the best way to do so. Lina also appreciates art in all forms and enjoys painting and sketching portraits in her free time.

Tom Kluemper 

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How Would YOU Treat This Patient? By Timothy Shaughnessy A 12 1/2-year-old boy presented for orthodontic treatment. The medical and dental history was insignificant. The patient’s chief complaint was his overbite and misalignment of the maxillary incisors. The INITIAL facial photographs (Figure 1) exhibit mild facial convexity and lip protrusion, but with lip competence. The INITIAL intraoral photographs (Figure 2) reveal a Class II dentition, deepbite, and mild incisor misalignment. The panoramic radiograph (Figure 3) shows a healthy permanent dentition with developing third molars. The cephalometric radiograph and analysis (Figure 4a and 4b) confirm an increased ANB value, along with other Class II skeletal measurements.

Figure 1: Initial Facial Photographs

It could be argued that the maxilla is more protrusive than the mandible is retrusive. In fact, when this boy postured his jaw forward to a Class I dental position, his profile became less attractive. Although the patient has a dental deepbite, the skeletal vertical dimension is reasonably normal. Both the maxillary and mandibular incisors are over erupted, relative to the posterior occlusal plane.

How would YOU treat this patient?

The Treatment Plan When devising the treatment plan for this patient, the clinician must decide how the occlusion is to be corrected. Will growth modification be incorporated, or tooth movement only? Will it be necessary to extract any permanent teeth? If so, which teeth, and how will this affect the anchorage requirements? The best treatment option should not only produce an esthetic and functional outcome, but it should be predictable and time efficient. If patient cooperation can be minimized, this would be even better.

Figure 2: Initial Intraoral Photographs

The Treatment Plan Options 1. Attempt to treat the patient via non-extraction therapy. This would require maxillary arch distalization and/or differential growth of the jaws following incisor decompensation. Mesial movement of the mandibular dentition would be an undesirable outcome. Although the mandibular incisors are measurably proclined, they are minimally misaligned and arguably in a reasonably stable initial position. Headgear for growth modification would be more ideal than a functional appliance, at least from the standpoint of mandibular incisor position. Any need for Class II elastics would also be a negative for the same reason. This plan is highly dependent on patient cooperation and favorable differential growth of the jaws.

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Figure 3: Pretreatment Panoramic Radiograph


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Figure 4a: Pretreatment cephalometric radiograph and analysis

June 2020

Figure 4b: Pretreatment cephalometric radiograph and analysis

2. Extract maxillary premolars and treat the patient to an Angle’s Class II molar relationship with a Class I canine relationship. This plan makes it a moderate anchorage situation because the molar relationship is not a full cusp Class II. In addition, a headgear could be used for both anchorage control and growth modification. Any amount of differential growth of the jaws would decrease the maxillary posterior anchorage demand.

of the mandible for Class II correction instead. The surgeon cautioned the family that the proposed extraction approach would cause sleep apnea, as a result of retracting the maxillary teeth and “compromising the airway”. A 6-month delay occurred as a result of the parents’ confliction regarding the proposed treatment plan and the disagreement between the specialists. This patient’s mom ultimately chose the extraction option because her older son was similarly and successfully treated in Texas prior to the family’s relocation to Georgia. The patient’s pediatric dentist agreed to extract the maxillary first premolars. Cervical-pull headgear was worn during en-masse space closure with a .016 x .022 closing loop arch wire in .018 brackets. The patient never wore Class II elastics.

3. Extract maxillary first premolars and mandibular second premolars and like Option 1, treat this patient to a Class I molar and canine occlusion. This plan will likely result in more retraction of the anterior teeth than the other two options. On a positive note, differential movement of the molars can contribute to Class I molar achievement. Class II elastics could be used in this effort without the same risk to mandibular incisor position as a mandibular non-extraction treatment plan.

The FINAL facial photographs (Figure 5) obtained at age 15 illustrate an esthetically pleasing outcome.

The Treatment Plan Chosen Maxillary right and left first premolars were removed. The lower arch was treated non-extraction. A small amount of mandibular incisor proclination was expected with leveling. This plan required the least amount of patient cooperation, whether headgear or Class II elastics. It also seemed to have the least chance of failure, i.e., not achieve Class I canine occlusion. Fixed appliances were initially placed on the maxillary teeth only to initiate bite opening. At +6 months, fixed appliances were placed in the mandibular arch. Following bite opening in both arches, the patient was referred to an oral surgeon for extraction of maxillary first premolars. The oral surgeon declined to extract the requested teeth, and urged the patient and his mother to consider surgical advancement

Figure 5: Final Facial Photographs

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Figure 6: Final Intraoral Photographs

The FINAL intraoral photographs (Figure 6) show good alignment of the teeth and a nice functional result. The chosen treatment plan was predictable and efficient, and lowest on the need for patient compliance to obtain an excellent outcome. The patient continues to sleep well at night. The total time in orthodontic treatment was 2 1/2 years, extended by six months when the extraction/sleep controversy ensued. The patient was referred to a different oral surgeon for extraction of the mandibular third molars. The maxillary third molars were not extracted because it appeared that they would erupt and function with the opposing second molars. The post-treatment panoramic radiograph (Figure 7) also demonstrates good root parallelism, including the maxillary extraction sites. The posttreatment cephalogram, its tracing and the cephalometric values (Figure 8a and 8b) confirm a reduction in the skeletal Class II discrepancy and no evidence of maxillary incisor retroclination as a result of space closure.

Figure 7: Posttreatment Panoramic Radiograph

Figure 8a: Posttreatment Cephalogram

Figure 8b: Posttreatment Cephalometric Values

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The pretreatment/posttreatment superimpositions (Figure 9) exhibit inhibition of maxillary growth, in combination with mandibular growth. Favorable differential growth of the jaws did decrease the maxillary posterior anchorage requirements. Contrary to what the oral surgeon predicted, there was no net change in the position of the maxillary central incisors-other than slight intrusion. The treatment did not “compromise the airway”, as the mandible grew forward!

presented to illustrate one way and the rationale for this treatment approach. At the end of the day, we all want to achieve an esthetically pleasing and functional result, with the greatest chance for long-term stability. This plan was chosen because it also seemed to be the most predictable and time efficient, with a reasonable amount of patient compliance required and anticipated.

It is easy, unfortunate, and often misguided for a non-orthodontic specialist to say something to a patient or parent that has no basis in fact. This case highlights such an example. It has become popular to suggest that extraction of teeth will compromise the airway and necessarily cause sleep apnea. The 2019 AAO white paper on this topic provides a fair synopsis of the current state of our understanding. Many clinicians may have treated this patient differently. The case report is

Figure 9: Pretreatment/Posttreatment Superimpositions

Education During COVID-19 Education of young orthodontists has been drastically impacted by COVID-19. Two people who are totally immersed in orthodontic education, Eladio DeLeon and Eser Tüfekçi, have shared their thoughts and their perspectives with the SAO News

Navigating through the COVID-19 Crisis and its impact on the Educational Process Eladio DeLeon Jr.

Augusta University, The Dental College of Georgia Commissioner, Orthodontics Commission on Dental Accreditation universities. The interruption of the orthodontic educational process has been a major source of stress for all our students/ fellows/residents, as well as the program faculty who are all looking for guidance on how to deal with this crisis. Most, if not all programs, stopped their clinical activities in mid-March and there are still many more weeks or months before treatment of patients can resume. Despite the tremendous efforts of our faculty to keep residents academically engaged during this time, there is considerable anxiety on how the loss of clinical time will impact the program’s compliance with the accreditation standards, the resident’s education, and graduation date.

As I write this note, I am praying that our SAO colleagues, their families, and practice teams are all doing well. This coronavirus tragedy has become a generational-defining crisis that we will never forget. We, as a nation, have been asked to sacrifice and change our ways for the common good. The uncertainty of where this is heading is extremely concerning. The coronavirus pandemic has had far-reaching consequences and sadly, it has brought our country and the world to a halt as we attempt to contain the spread and avoid the loss of lives. With no exception, the pandemic has affected educational systems worldwide, leading to the widespread closures of schools and

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June 2020 based requirements may be modified or reduced as long as the program can document that the program continues to comply with the Accreditation Standards and ensure the competence of their graduates.

This is when we must turn to the Commission on Dental Accreditation (CODA) for leadership and guidance. CODA serves the public and profession by developing and implementing accreditation standards that promote and monitor the continuous quality and improvement of dental education programs. CODA was established in 1975 and is nationally recognized by the United States Department of Education (USDE) as the sole agency to accredit dental and dental-related education programs. This interruption of the educational process has created an overwhelming and difficult challenge for CODA and since the start of this crisis, CODA has been collaborating with its stakeholders to seek solutions. The Commission recognizes that each educational program has an obligation and responsibility to ensure that its graduates of the Class of 2020 are competent and that the program complies with CODA’s Accreditation Standards.

Program length

Programs must document how the residents/fellows were engaged in alternative activities such as distance learning, board case preparation, virtual patient visits, or other activities during the period of interruption as long as the program can ensure the competence of their graduates. The program must track overall program hours. As mentioned, programs ceased their clinical activities in mid-March but they were not closed since most programs continued didactic education. Consequently, there is no modification to the minimum 24 months and 3,700 scheduled hour requirement for the orthodontic programs, and there is no change in the minimum of twelve months for the Orthodontic Fellowship training programs in Craniofacial and Special Care Orthodontics.

Through the collaboration and assessment of this issue, CODA has decided that the Orthodontic Standards, as written, must be met. However, as a result of this crisis, CODA is allowing “temporary flexibility” in the accreditation standards to address the interruption of education resulting from COVID-19 for the Class of 2020. There are three areas of “temporary flexibility”: alternative assessment methods, modification/reduction of curriculum content or curriculum requirement, and program length.

In summary, it must be emphasized that CODA evaluates the educational program’s compliance with Accreditation Standards, not the quality of each individual graduate. The “temporary flexibility” must result in comparable assessment and evaluation of the Class of 2020 residents to ensure that each resident is eligible for graduation from a CODA-accredited program. The program’s modifications to address the temporary flexibilities must be documented and reported to ensure the program complies with CODA Accreditation Standards.

Alternative assessment methods

Programs may determine the competency measures they will use, as long as they document that the graduates are competent. Clinical care is obviously preferred but alternative patient learning experiences such as scenario-based examination and simulations could be utilized. Programs can do whatever they feel is appropriate and defendable so long as they can ensure compliance and can provide documentation of these experiences.

As we recover, we know that there will be much change to every aspect of our life, but history has taught us that the hopelessness of this moment is temporary. We as a nation refuse to be defeated by impossible obstacles. We shall overcome this obstacle, and I’m wishing that all of you, as this threat is neutralized, will re-energize, pick up the pieces, and move on to an even better future.

Modification/reduction of Curriculum Content

Program-dictated requirements and/or CODA quantitative numbers-

Eladio DeLeon Jr.

Eser Tüfekçi

teledentistry was implemented. Research activities continued if the study design allowed the resident to work remotely; however, clinical studies or research involving human interaction were all put on hold at this time.

Professor, Department of Orthodontics Virginia Commonwealth University

We are lucky at VCU School of Dentistry as we had the virtual private network and other digital systems already in place for many years. Therefore, it was not a problem to remotely access Dolphin and Axium applications for patient care and continued treatment planning and analysis. Our residents have expressed their gratitude for the availability of the technology at our school as it has enabled us to hold our regular literature reviews, topical literature classes, and diagnosis and treatment planning seminars with Zoom without an interruption. While staying on track with the requirements of the residency program, our postgraduate students are in direct contact with all of their patients with regularly scheduled virtual orthodontic appointments. Although our residents know that they could certainly help their patients more in a clinical setting, they are confident that they are making the best out of the current situation. They all indicated that they miss working hands on with their patients.

In this unprecedented time, our faculty, staff, and residents have organized quickly and put together a system to meet the educational and clinical demands of our residency program. I can proudly say that the quick adaptation to these trying times helped us continue to advance in most aspects of orthodontic education under dire circumstances. We moved right away to online teaching and it seems our residents are busier than ever as their days are filled with our usual classes and seminars in addition to lectures provided by many of our alumni, the American Association of Orthodontists, University of North Carolina Orthodontic Department, and the Angle Society, to name a few. To monitor treatment progress, even modify treatment when indicated (discontinue or change elastics, check tracking and start new aligner series) and to handle emergencies,

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June 2020 had completed data collection on their research projects, so it was possible to finalize their research and to defend their theses digitally. Since they have each started about 100 patients, and now they have even a higher number of patients including transfer cases, they feel confident and ready for private practice. However, they are sincerely worried about their patients’ treatment progression without direct patient care intervention and they are sad that they may not see the final treatment outcome of some of their almost-completed cases.

Although our residents expressed anxiety at the beginning of the pandemic due to uncertainties, they all adjusted to the new norm reasonably well. It is somewhat relieving to hear residents say that they are actually learning a lot. With only virtual clinic activities, since clinic is the greatest component of many days at VCU, they have the time and opportunity to reflect and to improve on the areas they are lacking. It is the second year residents (we are a 24 month residency program) who reported anxiety about the upcoming and newly scheduled ABO written examination rescheduled for June, along with entering the workforce in a bleak orthodontic landscape after so many years of schooling and a high amount of student debt. Thankfully, all four graduating residents

Eser Tüfekçi

Every two years a group of “young” SAO members enrolls in the SAO Leadership Class. These young orthodontists are recommended for participation by their respective states. The 2019 group was divided into three sub groups. Each sub group worked on a “problem” in our specialty. The reports of each of these three sub groups are gladly published here in this issue of the SAO News.

Christian Johnson Christian Davilliar Celeste Block Sawsan Tabbaa Bryan Lockhart Mark Dusek (EC Liaison)

• • • • • •

SAO Green Team Leadership Project 2019

What’s In It For Us? Millennial Engagement in Organized Orthodontics SECTION 1: Millennials, also known as Generation Y, are the population demographic born between 1981-1996. The Pew Research Center has found that millennials tend to be more educated, racially diverse and ethnically diverse than their antecedent generation, Generation X (born between 1965 and 1996)1. The millennial population is on track to surpass the Baby Boomer generation as the largest age group in the population as early as 2019.2 Millennials are described as multitaskers, technologically engaged, economically conscious, and curious. They seek instant gratification/recognition, strive for work-

life balance, are team oriented, value authenticity/transparency, seek career advancement, and are drawn to brands with a mission. They have a short attention span, need constant stimulation, and are very visual.3 Education is of significant importance to millennials. 43% of millennial women and 36% of millennial men have a bachelor’s degree.1 One third of the labor force, 56 million people, are millennials.2 This segment of the population is represented in our specialty, orthodontics, and attention must be given to make sure this generation is active and engaged in organized orthodontics.

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Of the 9,525 practicing AAO members, approximately 2,378 fall within the millennial cohort. This number represents roughly 25% of practicing members. This is a group the AAO cannot afford to lose or have on the sidelines. From 2007 through 2019, the number of students transitioning to active AAO membership has been on the rise. In the fiscal year ending in 2007, 226 students transitioned to active membership, while a total of 302 students transitioned in the fiscal year ending in 2019. This represents a 33.6% increase in transitioning members. After transitioning to active membership, paying dues and attending constituent meetings is an important metric to ascertain


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how progress is being made on a larger level. As the specialty “ages”, it is important for millennials to become the next generation of leaders within the AAO and its constituent organizations.

Millennials, however, look to see how they can individually benefit from membership. Working in teams, along with frequent evaluations and feedback, is seen as crucial to meeting the expectations of millennials.4

In order to be able to encourage millennials to engage in organized orthodontics, it is important to understand the psychology and unique circumstances of millennials. As individuals who recently joined the workforce, they feel they can become involved in organized orthodontics later in their professional career. This fact makes it important to engage this group early in their career. When considering the millennial’s circumstances, student loan debt and practice debt are large deterrents to joining orthodontic organizations that have annual dues and meetings. Due to the high debt level of graduating residents, many are joining corporate practices instead of traditional private orthodontic practices. Several of these corporate practices host their own meetings and events, and young orthodontists might not feel they need to join or be involved with our national organization, the AAO and its constituent organizations. It’s also important to understand that millennials hold different views about what their relationship with an organization should be. Among older generations, a social contract belief was upheld. One would be willing to sacrifice on behalf of the company/organization as one’s career was seen as crucial to one’s identity.3

In order to attract millennials to organized orthodontics, we first have to understand how to get their attention. Christy Price researched ways to reach millennials. She found that there are five “R”s for engaging millennials: 1. Relevance: Millennials like to connect to current culture and make it relevant to their current life and future life. 2. Rationale: Millennials are more likely to follow through and accept a policy if they can rationalize the purpose. 3. Relaxed: Millennials prefer less formal events. 4. Rapport: Millennials like to connect on a personal level with those around them. 5. Research-based methods: Millennials are constantly connected. They prefer different teaching and learning methods which include podcasts, presentations, videos, and group projects.5

more “clout” AAO has when advocating on members’ behalves. With this goal in mind, we must have ALL orthodontists actively engaged in our organization – including millennials. To ensure that millennials remain engaged, steps must be taken to address their specific needs and interests. REFERENCES (1) Bialik, K. and Fry, Richard. “Millennial Life: How young adulthood today compares with prior generations”. Pew Research Center. https:// www.pewsocialtrends.org/essay/millennial-lifehow-young-adulthood-today-compares-withprior-generations/ (2) Fry, Richard. “Millennials are the largest generation in the U.S. labor force”. Pew Research Center. https://www.pewresearch.org/facttank/2018/04/11/millennials-largest-generationus-labor-force/ (3) “Teaching millennials: The Net Generation.” http://www.ast.org/Resource/ EducationPresentationArchives/IF/EC_2018/ TeachingMillennials/files/assets/common/ downloads/publication.pdf (4) Myers, Karen K. and Sadaghiani, K. “Millennials in the Workplace: A Communication Perspective on Millennials’ Organizational Relationships and Performance. J Bus Psychol. 2010; 25 (2):225-238.

Organized orthodontics is only as strong as its membership. Orthodontists act together via the AAO to lobby for patient interests, maintain a standard of care, and provide representation for orthodontics at the ADA. The greater the support of its members, the

(5) Price, C. “Why don’t my students think I’m groovy? The new “R”s for engaging millennial learners.” Millennial Traits and Teachings. http:// www.drtomlifvendahl.com/Millennial%20 Characteristics.pdf

solutions to combat the cost barrier to participation. These solutions include: free membership for new graduates, graduated dues for up to five years, and free/reduced meeting registrations. However, even with these incentives, other strategies have to be considered to maintain interest beyond the initial cost savings for membership in organized orthodontics.

what meetings are they attending? How are they deciding which meetings to attend? The competition for attracting meeting participants is increasing as the field of hosts for orthodontic meetings has greatly expanded. Not only are meetings being sponsored by our national organization, the AAO and its constituents, but also by orthodontic product companies, corporate orthodontic practices, and orthodontic social groups. Each of these facilitators have a unique drawing factor to entice attendance to their respective meeting. To effectively compete for millennials’ attendance at annual meetings, organized orthodontics must ascertain what millennials are interested in gaining from these meetings. Annual meetings may be intimidating due to the number of people in attendance, and it may seem there is

SECTION 2: Orthodontists who finished their programs between 2008-2017 have, on average, $418,722 of debt.1 Therefore, it is readily apparent that cost will impact the decision of millennials to participate in organized orthodontics. The cost to join the American Association of Orthodontists (AAO), membership in the national organization and the constituent/ component organizations, can range from $800-$1000+.2 When evaluating this expense against other expenses such as the cost of daily living (mortgage/rent, food expenses, transportation, etc.), loan repayment, and practice expenses, it is not surprising that a millennial orthodontist may be forced to forgo participation in organized orthodontics. Currently, orthodontic associations on the state, regional, and national levels have devised

Organized orthodontics must create more value to membership in the organization. Millennials have been dubbed the “Me” generation3 and as such, are likely influenced by the thought line, “What’s in it for me?”. A hallmark feature of participation in organized orthodontics is attendance at annual meetings. Questions that come to mind in this regard include: Are millennials attending orthodontic meetings? If yes,

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Quarter 2 limited ability to make new connections because there are just too many people. Having smaller breakout sessions or cocktail hours for new and young members will help to scale the size of the meeting to a manageable level and present an atmosphere where connecting with others is possible. Beyond the well-established benefits of continuing education, advocacy, and research, organized orthodontics has been tasked with developing new avenues of value. Fortunately, the resources are already in place to create more value! Of great value is the fact that current members can be utilized as mentors for those entering the specialty. Navigating the world of life and work can be overwhelming for a new orthodontist as the landscape of practicing orthodontics is ever evolving. Decisions that may seem monumental to a new orthodontist can be dissected into manageable smaller decisions with the guidance of a seasoned orthodontist. The development of working mentorship program can provide the compass a new orthodontist needs to make practice/ employment decisions (private practice, corporate orthodontics, partnership, ownership, etc.), team development/ management skills, scheduling tips, community involvement, loan repayment,

June 2020 etc. While mentorship relationships between new and experienced orthodontists probably already exist in an informal manner, a formal mentorship program could be a determining factor that encourages a millennial orthodontist to participate in organized orthodontics. In the same sense that meeting attendance and mentorship are important byproducts of membership, another valuable and possibly life changing benefit from participation in organized orthodontics is the personal relationships forged amongst members. While orthodontics is the initial common interest that draws individuals together, it quickly fades into the background as members discover they share many other commonalities and interests. These shared interests can lead to life-long meaningful friendships. Finally “early” engagement of millennial orthodontists in orthodontic organizations is key to millennial participation. Both the AAO and SAO have leadership tracks that, if one aspires to do so, lead to key/ influential positions within the organization. Many millennials, however, view these roles as something to be pursued later in one’s career – once they have attained a certain level of mastery of the clinical and business aspects of practicing orthodontics.

Organized orthodontics would do well to create entry-level leadership positions which are specifically reserved for new/ young members. The specialty must be committed to provide guidance in these roles. Participating in a leadership position will foster a sense of obligation to the organization and may influence the millennial orthodontist’s willingness to recruit other new members. As can be seen, the common theme for reaching and engaging millennials is making it personal.

REFERENCES (1) Orthodontists, A.A.O. Student Loan Survey. 2018 July 7, 2019; Available from: https://www. aaoinfo.org/sites/default/files/Orthodontic%20 Workforce%20Report_April%202018.pdf. (2) Application for American Association of Orthodontists Membership. 2019; Available from: https://www.aaoinfo.org/sites/default/ files/member-benefits-public/membership_ application-17-links.pdf. (3) Stein, J., Millennials: The Me Me Me Generation, in Time. 2013, Time Inc: New York City, NY.

SECTION 3: “Each One, Reach One” An engaged and growing membership is paramount to maintaining the vitality and longevity of the AAO and its constituent and component organizations. As such, it will require that each member take personal responsibility to recruit new members, especially new millennial orthodontists. The AAO might consider the initiation of a campaign for its members as it relates to membership. This campaign could be entitled “Each One, Reach One.” If each AAO member committed to either recruit a non-member orthodontist to join or to encourage a present member to become more involved, it would vastly increase membership numbers, membership participation, and engage members to work to ensure our specialty remains a highly respected, highly valued, and irreplaceable specialty within dentistry.

Within the hierarchical structure of organized orthodontics (component, constituent, and national), each level would have a crucial role in the “Each One, Reach One” campaign. The component or state-level organization will be key to residents transitioning from student membership to active membership upon graduation. Engaging residents during their residency program can come in the form of inviting them to the annual state meeting, and, if possible, covering the cost of attending the meeting. Hosting lunch and learns throughout the year would foster opportunities for relationships to be formed between practicing orthodontists and orthodontic residents. Also, the state organization could sponsor a graduation dinner for senior residents as a final reminder for them to transition to active membership in the AAO.

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The regional constituencies and the national organization can also have a part in “Each One, Reach One.” The AAO should consider conducting exit surveys of graduating residents in which it requests the residents to share information such as “In what state do you plan to practice and are you willing for your contact information to be shared with the state-level orthodontic association?”. This suggestion will allow the state-level organization to reach out to new orthodontists and welcome each one to the state, offer any assistance each may need as he/she transitions into practice, and invite the person to join the AAO if he/she is not already a member. If the new orthodontist is not already a member and decides to join, the goal of “Each One, Reach One” will have been achieved.


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The “Each One, Reach One” campaign will need to be marketed to our current membership in order to secure current member participation. Several marketing avenues already exist: the AAO website, AAO social media pages, and AAO publications. A general campaign with only the tagline may not resonate with many members and could be easily overlooked, but personal stories will empower members to believe that they can make a difference in the “Each One, Reach One” endeavor.

Brittany Reid Tom Garner Zac Levin Billy Neale Henry Rozen Sal Zammatti Beth Faber (EC Liaison)

• • • • • • •

Through AAO marketing, stories of existing “Each One, Reach One” relationships in our organization could be highlighted. Articles that describe how members could share stories of how they became involved in organized orthodontics and who encouraged them along the way, accompanied with photographs, could be written and disseminated through the different AAO media avenues.

Members who enlist in the “Each One, Reach One” campaign should receive an email or packet that describes many of the benefits offered by the AAO of which many orthodontists, both members and nonmembers, are unaware. This packet should also give suggestions of how to mentor others as well as provide new orthodontists’ contact information to state organizations. By taking a one-on-one personal approach, we believe the specialty can be successful in engaging millennial orthodontists in organized orthodontics.

SAO Blue Team Leadership Project 2019

How the AAO Works for You: Increasing Engagement for Our Future INTRODUCTION As dental professionals, we pledge to uphold high ethical standards to best serve our patients. To maintain a high standard of conduct for the specialty and to promote patient advocacy requires a collaborative effort among members. The American Association of Orthodontists (AAO) is the largest dental specialty organization in the world and, since its inception in 1900, has grown to represent over 18,000 members.1 The AAO provides several benefits for members of all experience levels. These include continuing education, practice management, legal and advocacy assistance, and career opportunities.1,2 The mission of the organization is to promote excellent patient care through these programs and research. The AAO’s stated purposes are: 1

THE PROBLEM 1. To promote the highest standards of excellence in orthodontic education and practice. 2. To encourage and sponsor research to advance the science and art of orthodontics. 3. To educate the public about the benefits of orthodontic treatment. 4. To provide advocacy and services that benefit a members’ pursuit of professional success. If membership in organized orthodontics is strong and member efforts are unified, our patients can benefit greatly.

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In 2016, Dr Courtney Dunn wrote a guest blog post for Orthopundit in which she presented several concerns with the current structure and leadership of the AAO and its benefits of membership. In her post, she cited several reasons why orthodontists may be failing to join the organization. Dr Dunn stated that the amount of student loan debt and the scarcity of jobs might deter new orthodontists from joining and participating in the organization and that “millennials” are typically more driven to join social media communities over traditional organizations. She also called for a diversification of leadership, new direction for the annual session, and overhaul of the current Consumer Advocacy Program (CAP).3


Quarter 2 Dr Dunn has transitioned from critic to advocate of the AAO and now serves on AAO’s Council on Communications (COC), but some of the same concerns she mentioned are still evident in the orthodontic community among colleagues on social media outlets (Figure 1).4 Despite the AAO’s efforts to provide resources to orthodontists, we suspect some orthodontists are choosing not to renew their membership and new orthodontists are failing to join the organization. We believe organized orthodontics is essential to preserving the specialty, so choosing not to maintain AAO membership (or failing to join the AAO) is counterproductive to the specialty as a whole. The goals of the current project were to investigate the following questions: •

Are orthodontists investing in other meetings outside of the AAO, and is this a trend with millennial orthodontists?

Do orthodontists understand the value in AAO membership?

Does financial obligation have an effect on the decision to join the AAO or renew membership?

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OUR PROJECT For this particular project, we provided a survey to members of the Southern Association of Orthodontists (SAO). A 20-question survey was compiled and emailed to all active SAO members after it was approved by the AAO Survey Review Committee using the most current member directory. Data was collected, analyzed, and compiled by the AAO data analysis team.

RESULTS & CONCLUSIONS The results provided survey answers from 181 respondents. The data from respondents was further subdivided into three cohorts based on practice experience: 0-10 years in practice, 11-20 years in practice, and 21+ years in practice. By nature of the survey distribution, all respondents were members of the AAO. According to the data, most respondents (52.5%) work 31-40 hours per week. Most are private solo practitioners. The majority of respondents (62.0%) practice in a suburban area. Many (36.3%) respondents have been practicing orthodontics for 30 years or more. A vast majority (97.1%) of respondents have been active members of the AAO for their entire career.

ARE ORTHODONTISTS INVESTING IN “OTHER” NON-TRADITIONAL MEETINGS? Most respondents are members of other organizations, i.e. ADA, Angle Society, etc. Most respondents attend “traditional” organization meetings such as the AAO, SAO, or state association meetings. Based on the results, the earlier an orthodontist is in his/her career, the more likely the person is to simultaneously be a member of several other organizations. The highest percentage of any cohort attending an “alternative/non-traditional” organization meeting was orthodontists practicing only 0-10 years; 8% have attended the OrthoPreneurs meeting. The OrthoPreneurs meeting was the most commonly attended “alternative/ non-traditional” meeting in all cohorts except for the 21+ cohort. The 21+ cohort most commonly attended the Mindset Knowledge Skill (MKS) meeting.

DOES FINANCIAL OBLIGATION HAVE AN EFFECT ON THE DECISION TO JOIN THE AAO? Most respondents reported that they believe the AAO is successful in achieving its stated purposes and most members are in favor of the AAO expanding its purpose to provide more value for dues. Overwhelmingly, AAO members who responded to this survey think their dues are used wisely. About 80% of respondents believe that the AAO should not reduce its goals or decrease the cost of dues. Only 43% of the respondent orthodontists have ever seen how their dues are spent, but 86% of them would find this information valuable. When asked directly about membership dues, most members favor dues in the $500-1000 range. As expected, members early in their career favor lower dues and members later in their careers are skewed slightly toward higher dues in the $1000-1500 range. Additionally, to have lower dues does not motivate most members (55%) to join/rejoin the AAO.

DO ORTHODONTISTS UNDERSTAND THE VALUE IN AAO MEMBERSHIP?

Figure 1: Current “chatter” among orthodontists on social media. OrthoPreneurs (Facebook Private Group) August 26, 2019

When provided with a list of comparative options from which to choose, members find Career Services, Practice Resources, and “Find an Orthodontist” as the least valuable benefits of their membership. They believe the biggest waste of members’ AAO dues are the Consumer

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Awareness Program (CAP) and Career Services. The main reasons these members maintain their memberships are the AAOendorsed Insurance Programs (AAOIC), the Annual Session continuing education, and the Legal Advocacy/Political Action Committee (PAC). When asked about the CAP directly, 70% of respondents report that the CAP is valuable; however, the perception of value for the CAP decreases with years in practice. When asked directly about the AAO-endorsed insurance programs, most respondents (73%+) reported that they value the AAOIC. This benefit is valued most by mid-career members (11-20 years), and members later in their career value this benefit the least (20+ years). When asked directly about the value of membership in organized orthodontics, most (70%+) respondents value membership as GoodExcellent. Furthermore, the perception of Good to Excellent value from membership increases with years in practice.

Chris Baker Eddy Sedeño Robin Mayo Arghavan Welch Wallie McCarlie Ahmad Abdelkarim Debbie Sema (EC Liaison)

• • • • • • •

RECOMMENDATIONS •

Find a way to efficiently and effectively ensure sure that every AAO member has access to the breakdown of how dues are spent.

Increase efforts to educate members about the benefits and results of CAP. This is a great benefit of AAO membership and should be promoted as such.

Members earlier in their careers may need additional assistance with dues and a way of enhancing their perception of the value of membership in the AAO.

Market/promote the VALUE OF MEMBERSHIP to the orthodontic residents and early (young) orthodontists.

In general, do not reduce fees for the purpose of increasing membership.

In general, continue to find ways to “stay relevant” in an ever-changing culture

REFERENCES (1) Mission and history, American Association of Orthodontists: https://www1.aaoinfo.org/ about-us/mission-history/. (2) “10 reasons to renew your AAO membership,” AAO: The Practice Management Bulletin, 2019; 37(3): 3-8. (3) Dunn, Dr Courtney. Does membership matter? The Progressive Orthodontist, Q2 2016; 78-79. www.orthopundit.com/doesmembership-matter/. (4) OrthoPreneurs (Facebook Private Group) August 26, 2019; Dr Nick Mann post

SAO Orange Team Leadership Project 2019

Patient Advocacy and Organized Dentistry: Identify the Issue and its Impact on Orthodontists As specialists in orthodontics, we are in a strong position to impact some of our fundamental responsibilities: to educate patients and to improve patient care. We can do these things individually. We can also do them collectively by being an active participant in organized dentistry. The mission of organized dentistry and of organized orthodontics is to advocate for patient-centered orthodontic care. Therefore, orthodontists and dentists have the legal, ethical, and moral duty to seek and advocate for treatment modalities that are in the best interest of patients.

There are currently a number of dental service organizations that seek to provide patients options to self-managed orthodontic care or do-it-yourself (DIY) orthodontics. These dental service organizations are located throughout the United States and successfully reach millions of consumers through marketing and promises to cut the “middle man”. These organizations follow several telemodels already adopted in retail, travel, dining, entertainment, and banking. Through these telemodels, patients can

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generate data from their own devices that can be immediately analyzed, graphed and shared. Challenges inherent to teledentistry that apply to DIY orthodontics are patient confidentiality, different standards of care across different states and deceptive marketing.1

DEFINITION OF ISSUES Teledentistry is a combination of telecommunications and dentistry delivered in order to provide care across


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long geographic distances.2 Teledentistry involves exchange of clinical information that is transferred in digital format between doctors and patients. It can be used for multiple purposes, including diagnosis and treatment planning, oral health consultation, treatment monitoring, appliance fabrication, or even on-site job training. Although modern teledentistry appears to be largely internet-based, teledentistry is vastly different from Web browsing and distance learning. Essentially, it is the sharing of digital information through communication technology, not direct personal contact, to provide dental care when distance separates the patient and the doctor. Technological advances in computers, smartphones, and digital diagnostic imaging have made partial or complete management of orthodontic patients by teledentistry more “vulnerable” than ever before. What follows is a review of the history, applications, legal concerns, and potential abuses of teledentistry in orthodontics, as well as its role in the emergence of do-it-yourself (DIY) braces and remote treatment-monitoring software.3

TELEDENTISTRY In 1984, computer aided design/computer aided manufacturing (CAD/CAM) entered the dental world with the advent of Chairside Economical Restoration of Esthetic Ceramics (CEREC) restorations.4 Three dimensional digital impressions in dentistry were first introduced in 1987 by CEREC (Siemens, Munich, Germany) using an infrared camera and optical power on the teeth to create a virtual model. In 2001, Cadent introduced the OrthoCAD® system for the production of 3D digital models, virtual occlusal setups, and indirectbonding trays. This was the first use of this technology in orthodontics and it had significant teledentistry implications. Either cast models or polyvinyl siloxane (PVS) impressions were sent to the OrthoCAD scanning center where the model or impression was scanned. The data was processed into a digital file that was downloaded into the practitioner’s office network. In 2006, Cadent developed the in-office iTero® digital impression system. The first in-office digital impression system capable of full-arch intraoral scanning came online in 2008. In late 2009, Cadent launched the iOC® system for iTero users. Align Technology purchased Cadent in 2011 and encouraged clinicians who had iOC to begin submitting 3D digital scans

June 2020

in place of physical impressions for the fabrication of Invisalign appliances.5 Intra-oral scanner devices offer numerous applications in orthodontics – study casts, indirect bonding, customized arch wires, customized fixed appliances (both labial and lingual), aligners, removable orthodontic appliances, and diagnostic procedures in both orthodontic and orthodontic/orthognathic surgical combined treatment. Advances in hardware and software technologies over time have drastically perfected this technology to effectively replace traditional alginate and polyvinyl siloxane (PVS) impressions in dentistry. This technology has led to increased possibilities for teledentistry in orthodontics. The “teledentistry” idea first started in “telemedicine”. Patients could contact medical specialists who were not in their specific location because specialists were not available in the patient’s location. Teledentistry was first implemented in 1994 by the US Army. Teledentistry has evolved in order to “increase access to dental care,” especially in rural areas.6 It has been used in advanced dental education to connect students at one location via telecommunications to doctors at another location who have specialized training.7

DIY ORTHODONTICS An example of DIY orthodontics is the practice of using rubber bands to close midline diastema gaps based on YouTube videos. In some of these cases, there are reports of severe damage to teeth and to the periodontal structures which have, on some occasions, resulted in loss of teeth. Currently, a trend is “at-home” clear aligners. The American Dental Association House of Delegates has considered and debated do-it-yourself (DIY) orthodontics in the past few years. This “at home” trend seems to include patients who are looking for less expensive treatment, putatively shorter treatment time, anonymity or something else. Today, there are many DIY dental service organizations. One DIY dental service organization, for example, is backed by a venture capital group that has also funded other large, successful companies.7 This DIY organization currently employs over 4000 people, has 200 “smile shop” locations and is valued at over 3 billion dollars – three times its

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valuation the previous year.8 It employs 225 licensed dentists/orthodontists who are the prescribing doctors for every patient. This organization collaborated in May 2019 with an American multinational information technology company to make the largest multi-jet Fusion 3D production facility in the US. In spite of all the market excitement, the company has not been free of patient complaints. In the last few years, several state dental boards have fulfilled their duty-bound responsibilities to enforce their respective dental practice acts which were passed and codified to insure that the public received a high standard of care. Recently, two state dental boards have been sued by DIY entities that claim that the DIY is not practicing dentistry. In both cases, the claims have been dismissed. In at least one of these cases, the AAO’s legal team served as the sole advocate for patient care, because not one practicing orthodondist was available to provide supporting testimony. Although the Association’s legal team is organized at the national level, there seems to be little or no locally organized infrastructure at the component or constituent level that can help with these issues. The minimal infrastructure found at the local level is an area that we have identified that has great potential for growth, especially with regard to advocating for patients.

ANALYSIS OF ROOT CAUSE(S) One of the reasons for the lack of minimal organized political infrastructure at the component or constituent level for patient advocacy is perhaps historical. State issues that impacted the practice of dentistry did not necessarily require a certain infrastructure or a nimble response system because the local issues originated externally rather than internally. With teledentistry, factors outside the locale may have a more significant influence upon local issues.

POSSIBLE SOLUTIONS OF THE ISSUE Though there are differing opinions, even within the orthodontic community, about how to advocate for patients, organized orthodontics offers balance to disparate factions and provides a basis for rational agreement as to how to best advocate for patients.


Quarter 2 Improving patient advocacy through constituent and component levels of the Association can happen at the state level in the following ways: 1. Encourage state dental board members to carry out duty-bound responsibilities to advocate for patients. 2. Develop relationships with legislators and educate them regarding patient advocacy through a localized, formal structure. 3. Reframe state dental boards in a way that strengthens the board’s ability to advocate for patients. Because the practice of dentistry is regulated by each state, local infrastructure is best suited to advocate for patients. A state dental board can enforce state laws that regulate the authorized practice of dentistry. We propose that the Southern Association of Orthodontists Board of Directors consider formally re-structuring component leadership to include a “legislative liaison” who would become a point-person and organizer of events and activities such as hosting a political “get to know you” for elected officials or for those running for office. This person

June 2020 would organize patient advocacy with state legislators. In conjunction with this suggestion, we propose the creation of a model or template in each state so that in each district of the state there is a team of orthodontists who form a political infrastructure that is charged to connect with every single representative and senator at the state level, similar to the Georgia Dental Association’s model for general dentistry.

HOW WILL PROGRESS BE MONITORED? Progress will be monitored by assessing whether or not these positions and teams have been created by the time of our next annual session. Events that are designed to engage more orthodontic specialists in the political process must be scheduled.

WHO WILL MONITOR PROGRESS AND BE ACCOUNTABLE? Common sense dictates that local leadership, and SAO component organizations should be accountable. Those components within the SAO include: West Virginia, Kentucky, Virginia, Tennessee, North Carolina, Mississippi, Alabama, Georgia, South Carolina, Louisiana, and Florida.

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References: 1. Sfikas, PM. Teledentistry: Legal and regulatory issues explored, J. Am. Dent. Assoc. 128:17161718, 1997. 2. Khan, SA, Omar, H. Teledentistry in practice: Literature review, Telemed. J.E. Health 19:565567, 2013. 3. Kravitz ND, Burris B, Butler D, Dabney CW. Teledentistry, Do-It-Yourself Orthodontics, and Remote Treatment Monitoring. J Clin Orthod. 2016;50(12):718-726. 4. Mörmann W, Brandestini M, Ferru A, Lutz F, Krejci I. Marginal adaptation of adhesive porcelain inlays in vitro. Schweiz Monatsschr Zahnmed. 1985;95:1118–1129. 5. Kravitz ND, Groth C, Jones PE, Graham JW, Redmond WR. Intraoral digital scanners. Journal of Clinical Orthodontics 2014;48: 337-47 6. Chen, Jung-Wei, et al. “Teledentistry and its use in dental education.” The Journal of the American Dental Association 134.3 (2003): 342-346. 7. Kravitz, N, et al. “Teledentistry, Do-ItYourself Orthodontics, and Remote Treatment Monitoring.” Journal of Clinical Orthodontics L.12 (2016): 718-726 8. Dickey, Megan Rose. “Teeth-Straightening Startup SmileDirectClub Is Now Worth $3.2 Billion.” TechCrunch, TechCrunch, 10 Oct. 2018, https://techcrunch.com/2018/10/10/teethstraightening-startup-smiledirectclub-is-nowworth-3-2-billion/.


Quarter 2

June 2020

Each year the SAO

sponsors research efforts in many graduate programs

that are located in the SAO

geographical area. This

research from the

West Virginia program

received SAO funding.

Identifying the Esthetically Optimal AP Position of Maxillary Incisors in Caucasian Females

MacKenzie Boyles-Horan, DDS, MS

Private practice, Morgantown, West Virginia

Chris A. Martin, DDS, MS

Professor, Department of Orthodontics West Virginia University School of Dentistry

Bryan Weaver, DDS, MD

Professor and Chair, Department of Oral and Maxillofacial Surgery West Virginia University School of Dentistry

Timothy Tremont, DMD, MS

Professor and Chair, Department of Orthodontics Medical University of South Carolina College of Dental Medicine

Jun Xiang, MS

Department of Family Medicine West Virginia University School of Medicine

Peter Ngan, DMD

Professor and Chair, Department of Orthodontics West Virginia University School of Dentistry

INTRODUCTION Evaluating the smiling profile should be a fundamental part of obtaining a complete orthodontic diagnosis.1 The soft tissue profile has been studied in abundance. However, there have not been many studies completed to evaluate the esthetics of the smiling profile. Most orthodontists do not routinely assess the relationship of the maxillary incisors directly to a facial landmark from a smiling profile perspective.1 Sarver and Ackerman suggested that in order to treat smiles, orthodontists need to visualize and quantify the smile statically and dynamically. They recommend that records include profile and oblique and frontal smile close-ups.2, 3 The ultimate position of the anterior teeth has a significant influence on the relationship of the lips and to the facial structure as a whole. The maxillary incisors should be angulated and also positioned most favorably in anterior-posterior and vertical relationships to all facial structures to ensure maximum facial harmony.4 Numerous soft tissue analyses have been developed to evaluate the esthetics of the soft tissue lips from a profile prospective. These analyses commonly determine the optimal position of the upper and lower lips relative to the subject’s soft tissue chin and nose. Rickett’s esthetic plane and the esthetic line of Steiner are widely used by orthodontists during the diagnosis and treatment planning phase of treatment. However, these analyses do not assess the soft tissue from an anteroposterior (AP) position when the dentition is displayed. Andrews proposed the use of the forehead as a landmark for assessing the AP position of the maxillary central incisors in the smiling profile.5 Treatment goals for adult white females should include that the maxillary central incisors be positioned somewhere between the forehead’s FFA point and glabella and correlated with forehead inclination.1 Andrews defined GALL (goal anterior limit line) as a line that parallels the head’s frontal plane and represents the optimal anterior border for the FA point of an Element I maxillary incisor.5 A study conducted by Tomblyn found that it is comparable or better to use Glabella Vertical, a vertical line tangent to soft tissue glabella, as a frontal plane compared to GALL.6

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June 2020

Additionally, there are currently no standard guidelines in which orthodontists and surgeons agree on when determining the optimal AP position of the maxilla when performing orthognathic surgeries. For example, Posnick stated that the optimal AP position of the maxilla is a range of what is considered proportionate and esthetic, not an exact millimeter number.7 Arnett commonly evaluates the patient’s profile angle, nasolabial angle, and maxillary sulcus contour when treatment planning maxillary orthognathic surgery.8,9 When comparing the esthetic opinions of orthodontic professionals and lay people, it has been determined that orthodontic professionals can sometimes be more critical of facial and smile esthetics.10 It is also important to be aware that cultural and ethnic differences play a role in what a person or population consider esthetic.11

Figure 1: Glabella Vertical line was used to determine the AP position of the maxillary incisors.

There have been no studies that have compared the esthetics of subjects from a lateral perspective in repose and smiling. The purpose of this study was to determine if there is a difference in perceived attractiveness between smiling and repose facial profiles, and to identify if there is an esthetically optimal AP position of the maxillary incisors in Caucasian females.

METHODS AND MATERIALS The protocol of this study was reviewed and approved by West Virginia University Institutional Review Board for human research protection (Protocol #1705573264). A sample of 30 young adult Caucasian females were positioned in Figure 2: Determining AP position relative to Glabella Vertical. adjusted natural head position and a repose profile photograph and a smiling profile photograph were taken with a millimeter ruler aligned with the subject’s midsagittal plane. The photographs were uploaded to Microsoft PowerPointTM and the distance from the subject’s Glabella Vertical plane and FA point of the maxillary incisor was measured (Figures 1 and 2). Six male and six female orthodontic faculty/residents and 10 male and 10 female nonorthodontic professionals rated the facial attractiveness of the subjects using a visual analog scale (Figure 3). The data was analyzed using two sample t-test, paired t-test, ANOVA, and chi-square analysis. Figure 3: Edited profile photos in black and white, repose shown on left and smiling shown on right.

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Quarter 2

June 2020

RESULTS There was a statistically significant (p<0.05) difference in perceived attractiveness of repose and smiling profiles in half of the photographed subjects (Table 1). The subjects with maxillary incisors that lie on Glabella Vertical were rated by orthodontists (p<0.05) more attractive than subjects with maxillary incisors positioned anterior or posterior to Glabella Vertical. Subjects with incisors that lie on Glabella Vertical or posterior to Glabella Vertical were rated (p<0.05) more attractive by non-orthodontists than subjects with maxillary incisors positioned anterior to Glabella Vertical (Table 2).

CONCLUSION Significant difference in perceived attractiveness of repose and smiling profiles in Caucasian females were found. Orthodontists rate maxillary incisors that lie on Glabella Vertical significantly more attractive than maxillary incisors that lie anterior or posterior to Glabella Vertical. Nonorthodontists rate maxillary incisors that lie on Glabella Vertical or lie posterior to Glabella Vertical more attractive than maxillary incisors that are positioned anterior to Glabella Vertical. Non-orthodontists appear to be more tolerant of retruded maxillary incisors from a lateral smiling perspective in Caucasian females.

Table 1: Smiling and repose mean ranked VAS score.

Table 2: Mean smiling VAS scores comparing orthodontists and non orthodontic professionals.

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Quarter 2

June 2020

The Council on Scientific Affairs is a vital cog in the wheel of

education of orthodontic

students. The SAO News is

pleased to include the COSA

report in this issue.

The Council on Scientific Affairs

With the 2020 in-person Annual Session canceled, most of the programs COSA manages at Annual Session had to be changed. The 2020 Hellman, Sicher, Graber Award winners have been invited to give their lecture at the 2021 Annual Session. Residents who applied

for the Resident Scholar Award have been encouraged to submit their research for the 2021 Hellman, Sicher, Graber awards. Accepted applicants for the 2020 Oral Research and Table Clinic programs were given the opportunity to present their research as an E-Posters. 356 E-Posters are available for viewing until July 31, 2020. COSA members were involved with the virtual Annual Session. Dr Emile Rossouw presented a lecture entitled ‘Stability: Is It An Elusive Goal?’. Dr Onur Kadioglu moderated four consecutive sessions on Saturday, May 2 from 8:30am–12:45pm and Dr Kelton Stewart moderated four consecutive sessions on Saturday, May 3 from 8:30am–12:45pm.

COSA members are playing an instrumental role in the AAO COVID-19 Task Force. Dr Eser Tüfekçi, the representative of the SAO constituent served on the task force with Drs Onur Kadioglu, James Mah, Greg Huang, Kelton Stewart, Rolf Behrents and Ms. Jackie Hittner. COSA was asked to review literature search results on aerosols which were used in the creation of the Interim Orthodontic PPE Summary Based on Current CDC and OSHA Guidelines which were posted on the AAO COVID-19 web page on May 6, 2020.

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Profile for Southern Association of Orthodontists

SAO June 2020  

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