Ortho V1 Sample [PDF]

Zitiervorschau

Vol. I

Orthodontics

Chris Chang & W. Eugene Roberts

Copyright Authors: Chris Chang, W. Eugene Roberts
 Publisher: Chris Chang
 Coordinator: Shu-Fen Kao
 Executive editor: Chester Chen-Hsun Yu
 Associate editors: Bill Su, Yu Lin Hsu, Sabrina Huang, Shu Ping Tseng, Ta-Yi Chen, Yu-Fang Chang
 English editor: Tzu-Han Huang
 Cover designer: Rungsi Thavarungkul
 Illustration editor: Rungsi Thavarungkul
 Technical Support Team: Jrting Shie, Dawson Hsiao, Shau Hua Lü, Rita Yeh, Jade Chen. Ron Tseng, Winnie Lü, Steven Hsiung, Hana Teng, Demeter Shih, Ginie Tang, Amanda Ku
 Consultants: Tom Pitts, John Jin-Jong Lin, Kwang Bum Park, Homa Zadeh, Johnny Liao, Frank Chang, Hong Po Chang, Dwight Damon, Larry White, Fernando Vizcaya, Tom Hans, How Kim Chuan, Mark Ou, Larry Wolford, Gil Schmidtke, Spring Hsu, Ching Liang Fang, Michael Steffen, Rungsi Thavarungkul, Tucker Haltom, Baldwin Marchack, Stephen Wallace Copyright © 2012 Newton’s A Co., Ltd. All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopy, recording, or any information storage and retrieval system, without permission in writing from the publisher. Newton’s A Co., Ltd
 2F., No.25, Jianzhong 1st Rd., East Dist., Hsinchu City 300, Taiwan (R.O.C.) Tel: 886-3-573-5676
 Fax: 886-3-573-6777
 Order Information: [email protected] ISBN: 978-986-08-6208-9 First published 2012.03 ii

Foreword In the 2006 Damon Forum, Dr. Dwight Damon remarked, “As an orthodontist, you should always challenge and commit yourself to be a far better orthodontist today than you were yesterday.” Today, I can honestly say that I am a better orthodontist than I was in the past. Seven years ago I started using the Damon system and TADs, and now this combination has provided a breakthrough for me as well as for my patients. Dr. Chris Chang published the first issue of News and Trends in Orthodontics (NTO) five years ago. At first, I didn’t think it’d turn out well. It’s very difficult to maintain a quarterly journal. Surprisingly Chris not only published the journal issue by issue but also steadily enriched the content over the years. It started with a few pages targeting mostly local audience, sharing useful tips about orthodontics. Now it has been expanded and transformed into a new publication, featuring orthoand implant-combined treatment, International Journal of Orthodontics and Implantology (IJOI). Each issue is about 100 pages long and distributed internationally.

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Over the years Chris has been in search for an objective system to measure the quality of our work. Now he recommends the American Board of Orthodontics (ABO) grading system as outstanding standards for evaluating our orthodontic practice. This ABO system has been applied in the American Association of Orthodontists (AAO) for years. It’s well recognized as a scientifc objective evaluation system in orthodontics. If we can routinely review our cases following the ABO system, without a doubt, we can signifcantly improve ourselves and promote the wellbeing of our patients. I am very glad that Chris has put together these clinical cases, previously published in the NTO & IJOI into a special collection. From this book we can gain a detailed understanding of how to utilize this ABO system for case review and these challenging clinical cases from start to finish. I am quite sure, if we can routinely examine our patients with the ABO system as the cases in this book, we can†all be far better orthodontists!

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Feedback on Orthodontics

“From this book we can gain a detailed understanding of

“Iʼm very excited about it. I hope I can contribute to this e-

how to utilize this ABO system for case review and these

book in someway.”

challenging clinical cases from start to finish.”

Dr. Tom Pitts, Reno, Nevadav, USA

Dr. John Jin-Jong Lin, Taipei, Taiwan “Chris Chang's genius and inspiration challenges all of us “No other book has orthodontic information with the latest

in the profession to strive for excellence, as we see him

techniques in treatment that can be seen in 3D format

routinely achieve the impossible.”

using iBooks Author. It's by far the best ever.“

Dr. Ron Bellohusen, Elmira, New York, USA

Dr. Don Drake, Sioux Fall, South Dakota, USA “This method of learning is quantum leap forward. My “Incredible Technology! It will be the future of teaching &

students at Oklahoma University will benefit greatly from

learning.”

Chris Chang's genius.“ Dr. Larry Wolford, Dallas,Texas, USA

“A great idea! The future of textbooks will go this way.” Dr. Javier. Prieto, Segovia, Spain

Dr. Mike Steffens, Edmond, Oklahoma, USA “Just brilliant, amazing! Thank you for the contribution.” Dr. Errol Yim, Honolulu, Hawaii, USA

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“Dr. Chris Chang's innovation eBook is at the cutting edge

“Tremendous educational innovation by a great

of Orthodontic Technology... very exciting! ”

orthodontist, teacher and friend.”

Dr. Doraida Abramowitz, Barton,Florida, USA

Dr. Keyes Townsend Jr, Colorado Spring, Colorado, USA

“The 21st century new way to educate our patients and an

“I am awed by your brilliance in simplifying a complex

awesome learning tool! Dr. Chang is way ahead of his

problem.”

time.”

Dr. Jerry Watanabe, San Ramo, California, USA Dr. Karen Guinn, Pasadena, California, USA “Beyond incredible! A more effective way of learning.”

“Dr. Chris Chang's first interactive digital textbook is

Dr. James Morrish Jr, Bradenton,Florida, USA

ground breaking and truly brilliant! ” Dr. John Freeman, San Luis Obispo, California, USA

“An electronic orthodontic textbook?! Incredible! Revolutionary! So is Dr. Chang!”

“The iBooks Author on Orthodontics, written by Drs. Chris

Dr. Karla Thompson, Pasadena, California, USA

Chang and Eugene Roberts is very informative and extraordinarily intuitive in the iPad format. It is an

“Congratulations! Great book! Dr. Chang, great

incredible teaching tool and portent of things to come.”

orthodontist.”

Dr. John Coombs, Carson City, Nevada, USA

Dr. Nasib Baiut, Mexico City, Mexico

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Dr. Thomas R. Pitts, founder of the Progressive Study Group. vii

Dr. Ron Bellohusen, Elmira, NY

Dr. Duncan Brown, Calgary, AB

Dr. Doug Hudson, Moraga, CA

Dr. Joe Lunsford, West Palm Beach, FL

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Preface

As orthodontists we have long been searching for the most efficient way to learn orthodontics. Irregardless one’s experience level we all agree case studies can provide rich and practical information for learning. There is probably no better way to learn about orthodontics than studying well documented cases based on theoretical foundation and scientific evidence. When Apple made an interactive e-publishing software, iBooks Author, available early this year, I have found an engaging and effective tool for learning. One can use several pages, even chapters to describe proper bonding positions or various applications of bone screws. However, this new software can display graphics and videos in a dynamic and interactive fashion. All that's hard to express clearly in words, can be understood easily by high quality visual aids. Forget about conventional ways of reading. Use your magic finger. The world of orthodontics is within a few touches away. Every once in a while a revolutionary product/idea/way of life comes your way. I believe the era of interactive learning has arrived. Be forewarned - if you pick up this book, your perception of reading and learning will never be the same again.

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Dr. Roberts (middle) and his winemaker Mike Just (left) and viticulture manager Damian Adams (right) at a New Zealand vineyard in 2010. xi

It is a pleasure to participate in this electronically published, clinical orthodontics atlas. A wide variety of malocclusions were treated to an optimal result with inventive mechanics. To me the most exciting clinical results involved the use of extra-alveolar temporary anchorage devices (E-A TADs) for nonextraction management of severe crowding, bimaxillary protrusion, and/or skeletal malocclusion. Orthodontic appliances were carefully selected, and anchorage was often controlled with E-A TADs. The most common sites for E-A TADs were the buccal shelf of the mandible and the infazygomatic crest of the maxilla. The mandibular buccal shelf can be palpated on the buccal aspect of the second molars. This ridge of ramal bone, that terminates on the lateral aspect of the posterior mandible, is often referred to as the external oblique ridge. As usually defined, the supra-alveolar ridge is the bone, on the superior and buccal aspect of the permanent maxillary first molar. This area is commonly referred to as the zygomatic eminence of the maxilla. The treatment goal for all of the patients in this series was a “board quality” result. In this regard, all patients were workedup and analyzed with the American Board of Orthodontics (ABO) Discrepancy Index (DI) and the Cast-Radiograph Evaluation (CRE). Additional methods were introduced for a more thorough diagnosis and treatment evaluation of impacted teeth, particularly difficult palatal and labial impactions of permanent maxillary canines. It is important to clarify that neither the ABO nor any of its directors were directly or indirectly involved in the evaluation or review of any of the cases presented in this volume. The ABO DI, CRE and case presentation templates were downloaded

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from the ABO website. The internationally recognized ABO techniques were selected as appropriate, contemporary outcomes to measure malocclusion complexity (severity) and post-treatment alignment (result) for all patients. Some of the published cases in this series were submitted for partial fulfillment of the clinical requirements for ABO certification. However, most of the cases published in this series have not been, nor are they likely to be, submitted to the ABO. Many of the published presentations are referred to as “ABO Case Reports” because the work-up and evaluation was according to the guidelines of the ABO, for presenting Phase III clinical records. In effect, this series of case reports relies on ABO methods of clinical evaluation as the state-of-the-art for quantifying complexity and assessing outcomes of orthodontic treatment, but there is no implication that there is any actual involvement with the ABO. In the opinion of the authors, all of the cases published in this volume are moderate to severe malocclusions that were treated to an optimal outcome. The emphasis was on a “board quality” result, if at all possible. There was an effort to document all the critical steps in the treatment process with photographs, radiographs and biomechanics details. This volume is intended as a clinical atlas demonstrating innovative approaches to diagnosis, treatment and evaluation of moderate to severe skeletal and/or dental malocclusions. We hope that all clinicians reading these case reports will find them to be of substantial benefit, for planning and executing the treatment of future patients.

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Acknowledgement For those who had helped to build this remarkable playground that we orthodontists can now enjoy playing everyday tirelessly, I want to begin by saying thank you. In the first 35 years of my life, my parents and two sisters worked hard to make sure I could spend every waking moment studying and not working for money. Without their unconditional love and support, I could never complete my PhD degree in Indiana University. I feel blessed to be part of this incredible family. That makes all the difference. Apart from orthodontics, I would like to acknowledge four unsung heroes that shaped the way I learn, practice and teach. They are my high school painting teacher, my golf coach from Japan, my violin professor from Indianapolis Symphony Orchestra and my guitar teacher. They all taught me the same lesson: stick to the basics. And that is the best advice I’ve ever received. It has been a long and exciting journey to compile this collection of clinical cases primarily treated in Beethoven Orthodontic Clinic, Hsinchu, Taiwan. I would like to thank our patients generously sharing a precious part of their life with us for the learning and teaching of orthodontics. The work of collecting and writing up the cases couldn’t be done without an excellent team of Beethoven’s lecturers: Drs. Bill Su, Yu Lin Hsu, Dennis Hsiao, Sabrina Huang, Hsueh Feng Chang, E-Young Su, Steven Wu, Shu Ping Tseng, Chia Ling Huang, Yi Lung Tsai, Hsin Yin Yeh, Jia Yuan Liang, Jack Cheng, Whe Wen Liu and Mina Peng. In addition, Drs. John Lin and Frederick J. Regennitter also contributed their cases and knowledge of the ABO system to this collection. Twenty-two years ago I was fortunate enough to become the first student of Dr. Eugene Roberts’ PhD program in Orthodontics and to witness his pioneer work of implant anchorage. Amongst those who had inspired me in this field include: Drs. Charles Burstone, James Baldwin, Lawrence Garretto, William Hohlt, Thomas Katona, Jie Chen, Gordon Arbuckle, Courtney Gorman, and Jeff Dean.

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Ten years ago Dr. Park’s MIA team, furthered the development and officially introduced this new and powerful weapon to our profession, Micro-Implant Anchorage. Here in Taiwan I want to thank Drs. Eric Liu, James Lin, Ming Gueg Tseng, Johnny Liao, and John Lin for their innovative work on the 2 mm, self-drilling miniscrews. Once again Dr. John Lin not only shared with me his work on miniscrews, but also brought me into the world of self-ligation system, in which leaders like Drs. Larry White, Dwight Damon, Tom Pitts and his brilliant colleagues at the Progressive Study Group showed me the wonders of what a continuous light force can achieve, especially with the combined use of miniscrews. These days self-ligation brackets and miniscrews have become the core treatment protocol of my practice. Furthermore, I couldn’t have been able to learn and later lecture about self-ligation systems without the kind help and friendship of Sandra Diver, Colin Matheson, Bob Davis and Oliver Gelles. The treatment of impaction cases is an important part of my work and interests. I want to thank Dr. Thomas Wang, who encouraged me to explore the field oral surgery 26 years ago. Dr. Wang assigned me to become teaching assistant for the orthognathic surgery giant, Dr. Chia-Ning Du. In those three years, I developed a life-long love and fascination for oral surgery. Later this training enabled me to have the knowledge and skills to perform operations for impaction treatment, in collaboration with my oral surgeon, Dr. Wei Chuan Chen. More recently, Dr. Homa Zadeh inspired me with his minimally invasive surgery which proves to be applicable in both implant and orthodontic field. His USC-Taiwan implant course significantly changed my approaches to impacted cuspid surgeries. Together Drs. Kwang Bum Park, Thomas Han, and Fernando Vizcaya are my greatest influence in developing implant-ortho combined treatment. In 2007 Dr. Roberts suggested me to join the Angle society, the Holy Grail for orthodontists. Becoming an ABO-certified Diplomate was one of the many pre-requisites. I can’t thank Dr. Roberts enough for his continuous challenges, even after leaving Indiana for more than 16 years. Adopting the ABO grading system for the evaluation of treatment result was, at first, only for the preparation of the certification process and is now a standard practice in my clinic and courses. These timeless standards are meant to be built to last forever. So we orthodontists worldwide are greatly in debt to the pioneers who contributed to the establishment of the ABO grading system. I also introduced this grading system to the International Association of Orthodontists and Implantologists (IAOI) and had since adopted it for

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the case reports and evaluation published in the International Journal of Orthodontics and Implantology. None of these can be realized without the selfless devotion from our examiners and consultants of IAOI, Drs. Eugene Roberts, Tom Pitts, John Lin, Kwang Bum Park, Homa Zadeh, Fernando Vizcaya, How Kim Chuan, Mark Ou, Larry Wolford, Gil Schmidtke, Frank Chang, Hong Po Chang, Spring Hsu, Ching Liang Fang, Michael Steffen, Rungsi Thavarungkul, Tucker Haltom, Larry White, Baldwin Marchack and Stephen Wallace. Last but not the least, I can’t say enough to express my sincere gratitude to the editing team in Yong Chieh, Ms. Megan Shao, the publishing team in EliteColor and my creative team in Newton’s A, Chester Yu, Dawson Shiao and Tzu Han Huang. I really appreciate their commitment and dedication to ensure the quality of this book. As people often say, behind every good man stands a great woman. I am forever in debt to the woman who always stands besides me and supports my wildest dream, Shufen. She is my girls’ best mother and my best friend and soulmate. Thank you. And one more thing. I want to give special thanks to Steve Jobs and his team who created Keynote and iBooks Author. Both Mac and these two softwares make the publication of this book and its electronic, interactive version an insanely great joy.

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Co-author: Drs. W. Eugene Roberts & James Baldwin Chapter 1

Objective Assessment of Orthodontics Clinical Outcomes

To objectively evaluate clinical case presentations, the

a thorough clinical assessment for quality assurance

American Board of Orthodontics (ABO) developed a series

purposes. The Indiana University Comprehensive Clinical

of methods for assessing malocclusion complexity and the

Assessment (CCA) method assesses additional factors

quality of the treatment result.1 Malocclusion complexity is

related to overall clinical management: facial and dental

determined with the Discrepancy Index (DI). From finish

esthetics, root resorption, arch-form symmetry, compliance

casts and panoramic radiographs, the finished occlusion is

(oral hygiene, keeping appointments and cooperation with

evaluated with the ABO Objective Grading System (OGS),

mechanics), treatment efficiency (result vs. time in active

which has been renamed the “Grading System for Casts

appliances), periodontium preservation, and growth

and Panoramic Radiographs” on the ABO website.1 The

management.3, 7-9, 13, 16

ABO Case Management Form (CMF) scores the treatment outcomes, relative to the clinician’s objectives, by assessing cephalometric tracings, measuring arch-widths on casts, and determining the overall quality of the case records. The DI, OGS and CMF methods are designed to determine if case records presented by a candidate meet

Collectively, the ABO (DI, OGS) and the Indiana CCA methods are effective tools for quality assessment of clinical orthodontics.3, 7-9 ,13-14, 16 This article summarizes the methods and provides references for the detailed application of the techniques.

the minimal standards of the ABO for certification purposes. Although the CMF has only been used for examination purposes, the DI and OGS have proven to be helpful for a variety of orthodontics outcome assessments. 2-3, 5, 7-9, 10-17

The ABO case evaluation methods were not designed for comprehensive outcomes analysis, so they do not provide 18

1 ABO Discrepancy Index

The Discrepancy Index (DI) method was introduced by the ABO in 2005.18 The method has been independently validated as an indicator of malocclusion complexity.3, 7, 12, 14, 16

A recent report by Pulfer et al.14 assessed the DI for

716 consecutive patients with permanent dentition and found it to be a reliable and relatively stable index for measuring malocclusion complexity; however, it is not a reliable predictor of outcomes.14 These data are a positive reflection on routine clinical standards because an optimal result was achieved for most patients regardless of the malocclusion complexity. On the other hand, the treatment duration is related to the DI, indicating it takes more time and effort to treat a complex malocclusion. Thus, the DI is an indicator of probable clinical effort that can be used as a guide for assigning fees for treatment that are fair to both the patient and the doctor. Fig. 1 is the scoring form for the DI. Detailed instructions for scoring the complexity of a malocclusion with the DI method are available on the ABO website.1 Fig. 1 Discrepancy index worksheet 19

20

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2 ABO Objective Grading System

The objective grading system (OGS) was introduced by

been numerous major revisions related to variable dental

the ABO in 1984 and was first used for the 1999 Phase III

anatomy and weighting of scores: 1. Marginal ridges -

clinical examination. The OGS is part of the ABO effort to

mesial marginal ridge of mandibular first premolars are

make the clinical examination a fair, accurate, and

not scored, 2. Maxillary cusps - neither diminutive

meaningful experience for examinees.1 As previously

distolingual cusps of maxillary molars nor lingual cups of

mentioned, the ABO now refers to the OGS as the

maxillary first premolars are scored, 3. Mandibular

Grading System for Casts and Panoramic Radiographs,

occlusal contacts - no more than two points can be scored

however, most outcomes references in the literature still

per tooth, and 4. Canine root angulation - omit scoring the

refer it as the OGS.2-13, 15-17 This objective method has

canine root alignment because of inherent distortion in

helped to: 1. enhance the reliability of the ABO clinical

many radiographs.1 Although a score of < 30 was

examiners, 2. provide the candidates with a reliable tool

originally considered to be potentially acceptable for board

for self-assessment of finished orthodontics results, and 3.

purposes,2 these revisions in scoring have decreased the

assist candidates in selecting cases to present to the

acceptable limit to 26 points.1

board examiners.1

The OGS is not a comprehensive outcome assessment

It is important for investigators to realize the OGS is an

for orthodontics treatment because it only scores casts

evolving method that is periodically revised to improve its

and panoramic radiographs.1,4 However, independent

performance as a clinical examination tool. There have

clinical research has demonstrated that the OGS and

22

Comprehensive Clinical Assessment (CCA) methods are complimentary, and their respective scores are positively correlated.8 ,9 ,13 These data indicate that when clinicians achieve an acceptable alignment of the dentition, as evidenced by an OGS score < 26 points,1 they usually produce an optimal result from a more comprehensive perspective. This is an important validation of the OGS score for testing purposes, but it does not qualify the method as a comprehensive outcome assessment. Over the years, numerous investigators have shown that the OGS method is both valid and reliable for routine scoring of clinical alignment.2,3,5,7-9,12,13,15-17 However, each use in clinical research must be specifically calibrated, because of sample variation, interexaminer error, and the progressive incorporation of refinements. It is not reliable to compare scores that were derived using different variations of the method. Comparable scores require a specific calibration based on a specific stage of refinement of the OGS method. Fig. 2 is the current OGS form for scoring orthodontic alignment, utilizing casts and panoramic radiographs; an original can be downloaded from the ABO website.1 The

Fig. 2 Objective grading system form 23

Fig. 3 A. The right aspect of the gauge is used to measure 1 mm increments relative to discrepancies in alignment, overjet, occlusal contact, interproximal contact, and occlusal relationships. The width of this gauge extension is 0.5 mm. B. The superior surface of the gauge has graduated steps measuring 1 mm in height and is used to assess discrepancies in mandibular posterior buccolingual inclination (3rd order alignment). C. The left aspect is of the gauge has graduated steps measuring 1 mm in height and is used to evaluate discrepancies in marginal ridges. D. The inferior surface of the gauge has graduated indentations of 1mm each which are used to evaluate discrepancies in maxillary posterior buccolingual inclination (3rd order alignment).

ABO designed a special tool (gauge) for measuring overjet, marginal ridge discrepancies, lack of cusp contact, as well as axial inclination of premolars and molars. The gauge can be purchased from the ABO or custom manufactured according to the specifications shown if Fig. 3. Complete details for the OGS method and use of the gauge are provided by a link to Grading System for Casts and Panoramic Radiographs on the ABO website.1 A new interactive series of forms is now available for all aspects of the ABO case workup, including the DI, OGS and CMF.1

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25

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3 Comprehensive Clinical Assessment (CCA)

Orthodontics faculty at Indiana University developed the CCA method to supplement OGS scores for use as a comprehensive assessment of clinical outcomes for a consecutive series of orthodontics patients.8, 13 Relative to the OGS scoring of casts and panoramic radiographs, the CCA method assesses additional factors related to overall clinical performance: facial and dental esthetics, root resorption, arch-form symmetry, compliance (oral hygiene, keeping appointments and cooperation with mechanics), treatment efficiency (result vs. time in active appliances), periodontium preservation, and growth management. This article is the first publication of the most recent revision of the CCA method. The current scoring criteria and dataentry form for the CCA method is shown in section 6 in this chapter. Although OGS and CCA scores have proven to be positively correlated, the use of both methods provides the most reliable comprehensive outcome assessment for routine orthodontics treatment.3, 7-9, 13, 16 27

4 Conclusions

Question 1 of 8 • OGS method has evolved into a reliable and efficient assessment of the finished orthodontic alignment. • DI has proven to be an effective indicator of malocclusion complexity (severity) for a wide variety of

The ABO Objective Grading System for scoring dental casts and panoramic radiographs contains eight criteria: alignment, marginal ridges, buccolingual inclination, occlusal relationships, occlusal contacts, overjet, interproximal contacts, and root angulation.

patients. • DI can be used as a guide for determining a fair fee based on probable clinical effort. • CCA method evaluates a broader array of clinical outcomes such as esthetics, root resorption, symmetry, compliance, treatment efficiency, periodontium preservation, and growth management. • Collectively, the DI, OGS and CCA methods provide a

A.

True

B.

False

reliable assessment of orthodontics clinical outcomes relative to malocclusion severity. • Routine outcome assessments are essential for establishing and maintaining quality control in an orthodontics practice. Check Answer

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5 References

1. American Board of Orthodontics Website: http:// www.americanboardortho.com, accessed July22, 2009. 2. Abei Y, Nelson S, Amberman BD, Hans MG. Comparing orthodontic treatment outcome between orthodontists and general dentists with the ABO index. Am J Orthod Dentofacial Orthop 2004;126:544-548. 3. Campbell CL, Roberts WE, Hartsfield JK, Jr., Qi R. Treatment outcomes in a graduate orthodontic clinic for cases defined by the American Board of Orthodontics malocclusion categories. Am J Orthod Dentofacial Orthop 2007;132:822-829. 4. Casko JS, Vaden JL, Kokich VG, Damone J, James RD, Cangialosi TJ et al. Objective grading system for dental casts and panoramic radiographs. American Board of Orthodontics. Am J Orthod Dentofacial Orthop 1998;114:589-599. 5. Cook DR, Harris EF, Vaden JL. Comparison of university and private-practice orthodontic treatment outcomes with the American Board of Orthodontics objective grading system. Am J Orthod Dentofacial Orthop 2005;127:707-712.

6. Costalos PA, Sarraf K, Cangialosi TJ, Efstratiadis S. Evaluation of the accuracy of digital model analysis for the American Board of Orthodontics objective grading system for dental casts. Am J Orthod Dentofacial Orthop 2005;128:624-629. 7. Deguchi T, Honjo T, Fukunaga T, Miyawaki S, Roberts WE, Takano-Yamamoto T. Clinical assessment of orthodontic outcomes with the peer assessment rating, discrepancy index, objective grading system, and comprehensive clinical assessment. Am J Orthod Dentofacial Orthop 2005;127:434-443. 8. Hsieh TJ, Pinskaya Y, Roberts WE. Assessment of orthodontic treatment outcomes: early treatment versus late treatment. Angle Orthod 2005;75:162-170. 9. Knierim K, Roberts WE, Hartsfield J, Jr. Assessing treatment outcomes for a graduate orthodontics program: follow-up study for the classes of 2001-2003. Am J Orthod Dentofacial Orthop 2006;130:648-655, 655 e641-643. 10.Murakami K, Deguchi T, Hashimoto T, Imai M, Miyawaki S, Takano-Yamamoto T. Need for training sessions for orthodontists in the use of the American Board of Orthodontics objective 29

grading system. Am J Orthod Dentofacial Orthop 2007;132:427 e421-426. 11.Nett BC, Huang GJ. Long-term posttreatment changes measured by the American Board of Orthodontics objective grading system. Am J Orthod Dentofacial Orthop 2005;127:444-450; quiz 516. 12.Park Y, Hartsfield JK, Katona TR, Eugene Roberts W. Tooth

17.Wes Fleming J, Buschang PH, Kim KB, Oliver DR. Posttreatment occlusal variability among angle Class I nonextraction patients. Angle Orthod 2008;78:625-630. 18.Riolo, M. L., S. E. Owens, et al. (2005). "ABO resident clinical outcomes study: case complexity as measured by the discrepancy index." Am J Orthod Dentofacial Orthop 127 (2): 161-3.

positioner effects on occlusal contacts and treatment outcomes. Angle Orthod 2008;78:1050-1056. 13.Pinskaya YB, Hsieh TJ, Roberts WE, Hartsfield JK. Comprehensive clinical evaluation as an outcome assessment for a graduate orthodontics program. Am J Orthod Dentofacial Orthop 2004;126:533-543. 14.Pulfer RM, Drake CT, Maupome G, Eckert GJ, Roberts WE. The association of malocclusion complexity and orthodontic treatment outcomes. Angle Orthod 2009;79:468-472. 15.Schabel BJ, McNamara JA, Baccetti T, Franchi L, Jamieson SA. The relationship between posttreatment smile esthetics and the ABO Objective Grading System. Angle Orthod 2008;78:579-584. 16.Vu CQ, Roberts WE, Hartsfield JK, Jr., Ofner S. Treatment complexity index for assessing the relationship of treatment duration and outcomes in a graduate orthodontics clinic. Am J Orthod Dentofacial Orthop 2008;133:9 e1-13.

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6 CCA Scoring Criteria

CCA Scoring Criteria - no more than 5 points scored for each category 1.# Compliance: Failures, Poor Oral Hygiene, Tx Cooperation# #

(1 pt for every 2 notes per category up to maximum of 5)

2.# Records Quality:# #

(5)________

(5)________

Number of A or B records missing or of poor quality (1-5)

3.# Facial Esthetics:#

(5)________

• Frontal Symmetry: no improvement or deterioration (1-2) • Profile: no improvement or deterioration from ideal (1-2) • Smile Line: no improvement or deterioration (1-2) 4.# Dental Esthetics:#

(5)________

• Enamel Surfaces: residual bonding resin or enamel scars (1-2) • Dentition: embrasures, incisal edges, black triangles & corridors (1-2) • Decalcifications: moderate to severe (1-2) 5.# Vertical Control:#

(5)________

• Growth Management: no improvement or deterioration (1-2) • Lip Competence: no improvement or deterioration (1-2) 31

• Incisal Exposure: no improvement or deterioration (1-2) 6.# Arch-Forms:#

(5)________

• Symmetric: moderate to marked discrepancy (1-2) • Coordinated: moderate to marked Mx/Mn discrepancy (1-2) • Dentition over Basilar Bone: to tonsillar pillars and apical base (1-2) 7.# Periodontium Management:#

(5)________

• Bone Loss: moderate to severe, localized or generalized (1-2) • Recession: moderate to severe, localized or generalized (1-2) • Gingival Clefts: moderate to severe, localized or generalized (1-2) • Gingivitis: moderate to severe (1-2) 8.# Root Structure Preservation: root resorption#

(5)________

• Incisors: moderate to severe, localized or generalized (1-2) • Cuspids, Bicuspids: moderate to severe, localized or generalized (1-2) • Molars: moderate to severe, localized or generalized (1-2) 9.# Treatment Efficiency: result attained relative to treatment time#

(5)________

• Overall Result: moderate to severe compromise (1-2) • Exceeds Expected Tx Time: one point per 6 mo. increment (3)

#

TOTAL________ 32

About the Authors Dr. Chris Chang Dr. Chris Chang received his PhD in bone physiology and Certificate in Orthodontics from Indiana University in 1996. Dr. Chang is a Diplomate of American Board of Orthodontics (ABO). He is author of iAOI workbook, iAOI Case Reports, Jobsology and publisher of International Journal of Orthodontics and Implantology (IJOI). Dr. Chang is frequently invited worldwide to lecture on a wide range of topics, including the Damon system, impaction treatment, OrthoBoneScrews, implant-orthodontic combined treatment and Jobs’ effective presentations. In addition to teaching and private practice, he also founded Newton’s A, Inc. and Beethoven Orthodontic Group in Taiwan and produces a podcast series, Podcast Encyclopedia in Orthodontics as an innovative E-learning tool. He has been actively involved in the design of orthodontic bone screws and application on impaction treatment. His latest focus is implant and orthodontic combined treatment.

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Dr. W. Eugene Roberts Dr. Roberts received a DDS from Creighton University, a PhD in Anatomy from the University of Utah, and Clinical Certification in Orthodontics from the University of Connecticut. Docteur Honoris Causa (honorary doctorate in medicine) was awarded by the Faculty of Medicine, University of Lille II, Lille, France. He is a Fellow of the American College of Dentists, a Fellow of the International College of Dentists, a Diplomate of the American Board of Orthodontics (ABO), and an active member of the Midwest Component of the Angle Society. Dr. Roberts is Professor Emeritus of Orthodontics at Indiana University, Adjunct Professor of Mechanical Engineering at Purdue University School of Engineering and Technology, and Associate Professor of Maxillofacial Implantology in the Faculty of Medicine at the University of Lille in France. Dr. Roberts is active in the American Association of Orthodontists (AAO) as the Chairman of the Council on Orthodontic Education; he serves as a delegate and member of the Board of Directors of the Great Lakes Association of Orthodontists. He practices orthodontics with his son Jeffery in southeast Indianapolis at Roberts Orthodontics.com. Honors include US Navy Commendation Medal with Combat V, Isaiah Lew Memorial Research Award American Academy of Implant Dentistry Foundation, Jarabak Award for Orthodontic Education and Research - AAO Foundation, Salzmann Lecture - AAO Foundation, and the Dr. Dale Wade Award for Excellence in Orthodontics-ABO. Dr. Roberts has presented multiple endowed lectures and served as a visiting professor both nationally and internationally.

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Dear Friends, my name is Chris Chang from Taiwan. I’m so excited about this ebook and how Apple’s technology makes learning orthodontics so fun and easy. I hope you enjoyed learning these complex cases through these beautifully shot videos and pictures as much as we do. 
 I truly believe these board quality case reports can provide lots of hands-on knowledge of orthodontic treatment. You can find out more about my latest videos on our youtube Channel, If you have cases you wish to share or discuss, feel free to shoot me an email. I would love to hear from you! xxxvi

Hello, I am Eugene Roberts, professor of Emeritus of Orthodontics at Indiana University and also the adjunct professor at mechanical engineering at Purdue here in Indianapolis, Indiana. 
 It's a pleasure to work with Chris Chang really throughout his career in developing his ability to teach remarkable cases with multimedia. Chris was my first Ph.D student at Indiana University some years ago and from that time he is going on to achieving great clinical heights and in particular his ability is to use extra alveolar TADs to treat patients that would be otherwise surgical problems. As he treats so many cases nonsurgically, with TADs placed in the infrazygomatic crest area and also in the buccal shelf. I think it is truly remarkable. It's a new paradigm in our profession. Chris has also achieved the American Board certification and he is now in advanced affiliate in the Midwest component of the Angle society and I have been very pleased with Chris' progress' in working with them. Again, he is a remarkable person. Another thing that he's done is he is into sculpture. This is a particular sculpture that he prepared at Edward Hartley Angle. It sits on the shelf behind me. We have one in metal and another one is in glass. Many of the things that Chris has done...He has been a musician, he has been a sculptor he is an Angle historian and beside that he is an outstanding clinician. And I think you will enjoy very much this new idea of ebooks and the ability to use multimedia presentations to train yourself in advanced methods of orthodontics. Thank you very much.

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