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The American Board of Orthodontics (ABO) has updated its clinical examination process to remove barriers to the case-based examination and to distinguish board-certified orthodontists from uncertified dental practitioners who provide orthodontic care. In 2017, the ABO took the bold step of adopting a new clinical examination format (a scenario-based examination), thereby, addressing the challenges that were inherent in the former case-based examination format. The coronavirus disease 2019 pandemic forced the scenario-based clinical examination scheduled for July 2020 to be canceled. This caused the ABO to regroup and adapt the scenario-based clinical examination to a format that could be administered worldwide in a testing center environment, eliminating the need to travel to St Louis, Missouri. The ABO-written examination remained unaltered. Since the scenario-based format was adopted, 63% of the AAO members are now board-certified, and the trend is upward. In support of our mission to elevate the quality of orthodontics through certification, education, and professional collaboration, the ABO is responsible for certifying orthodontists in a fair, reliable, and valid manner. This requires continuous evaluation and review of our certification process to ensure that our examination reliably evaluates the ability of orthodontists to provide the highest level of patient care.

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OBJECTIVE: To analyze and compare the effects of a traditional laboratory-fabricated Hyrax expander (T-Hyrax) and two different 3D-printed Hyrax expander models relative to tension points, force distribution, and areas of concentration in the craniofacial complex during maxillary expansion using finite element analysis. MATERIALS AND METHODS: Three maxillary expanders with similar designs, but various alloys were modeled: a T-Hyrax, a fully printed Hyrax (F-Hyrax), and a hybrid printed Hyrax (H-Hyrax). The stress distributions and magnitude of displacements were assessed with a 5 mm expansion in a symmetrical finite element model. The areas of interest included the teeth, alveolar processes, midpalatal suture, nasal complex, circummaxillary sutures (CS), and the expanders themselves. RESULTS: The highest stress value (29.2 MPa) was found at the midpalatal suture of the F-Hyrax, while the lowest stress (0.90 MPa) was found at the temporozygomatic suture in the T-Hyrax. On average, the F-Hyrax increased stress at the CS by 24.76% compared with the T-Hyrax and H-Hyrax. The largest displacements were found at the upper incisor (U1) and anterior nasal spine (ANS). The findings indicated an average increase of 12.80% displacement at the CS using the F-Hyrax compared to the T-Hyrax. CONCLUSION: The F-Hyrax exerts more stress and displacement on the maxilla than both the T-Hyrax and H-Hyrax, where the weak link appears to be the solder joint.

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STUDY OBJECTIVES: Maxillomandibular advancement (MMA) is an effective surgical option for patients suffering from obstructive sleep apnea (OSA). As a relatively new treatment option, patients may turn to the Internet to learn more. However, online patient education materials (OPEMs) on MMA may be written at a higher literacy level than recommended for patients. The aim of this study was to analyze the readability of OPEMs on MMA. METHODS: A Google search of "maxillomandibular advancement" was performed, and the first 100 results were screened. Websites that met eligibility criteria were analyzed for their readability using the Automated Readability Index (ARI), Coleman-Liau Index (CLI), Flesch-Kincaid Grade Level (FKGL), Gunning Fog (GF), and Simple Measure of Gobbledygook (SMOG) and compared to the recommended sixth-grade reading level using one-tailed t tests. Readability scores were compared based on the type of website, including hospitals/universities or physician clinics, using ANOVA tests. RESULTS: The mean (SD) for ARI, CLI, FKGL, GF, and SMOG was 11.91 (2.43), 13.42 (1.81), 11.91 (2.06), 14.32 (2.34), and 13.99 (1.56), respectively. All readability scores were significantly higher than a sixth-grade reading level (p < 0.001). After comparing readability scores between different website types (university/hospital, clinic, and other), there was no statistical difference found. CONCLUSIONS: The available OPEMs on MMA surgery for OSA are above the recommended sixth-grade reading level. Identifying and reducing the gap between the reading levels of OPEMs and the reading level of the patient are needed to encourage a more active role, informed decisions, and better patient satisfaction.

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An understanding of fundamental orthodontic principles involving diagnosis, treatment planning, and clinical strategies is essential for achieving successful outcomes in the treatment of craniofacial patients, particularly cleft lip/palate. This article focuses on: customizing a mandibular dental arch form using the WALA ridge; accurately diagnosing the maxillary skeletal transverse dimension (cusp to cusp/fossa to fossa); coordinating the upper dental arch with the lower; using a smiling profile and glabella vertical to assess anteroposterior jaw position; and leveling the mandibular curve of Spee while considering the lower one-third of the face. These concepts influence treatment outcomes to the extent they are used.

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OBJECTIVES: To determine an optimal anteroposterior (AP) position of the maxillary central incisors and their relationship to the forehead in adult African American (AA) females. MATERIALS AND METHODS: Smile profile photographs of 150 AA females were acquired and divided into an optimal control group (N = 48) and a study group (N = 102) based on the position of the maxillary central incisors, as judged by a panel of orthodontists and orthodontic residents. The AP position of the maxillary central incisors and the forehead inclination (FI) were measured relative to Glabella vertical (GV). A two-sample t-test was used to compare the incisor AP position and the FI between the two groups. Linear regression was used to quantify the relationship between the incisor AP position and the FI. RESULTS: In all groups, the maxillary incisors were anterior to GV. However, a significant difference was found in the incisor AP position between the groups (8.58 ± 3.96 mm for the control group and 11.2 ± 4.48 mm for the study group; P = .001). Furthermore, the control group demonstrated a positive association between the optimal AP position of the maxillary central incisors and FI ( P < .0001). CONCLUSIONS: GV is a reliable landmark with which to access the AP maxillary incisor position in AA females. The optimal AP position of the maxillary central incisors is significantly associated with FI; the greater the FI, the more anterior the optimal maxillary incisor position. A prediction equation to determine the optimal position of the maxillary incisors relative to GV for AA females is proposed.

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PURPOSE: The purpose of the present study was to document the malocclusion and facial dysmorphology in primary mandibular deficiency (PMD) subjects with chronic obstructive nasal breathing before treatment and the outcomes after bimaxillary orthognathic, genioplasty, and intranasal surgery. PATIENTS AND METHODS: A retrospective cohort study of PMD subjects undergoing bimaxillary, chin, and intranasal surgery was implemented. The predictor variables were grouped into demographic, anatomic, operative, and longitudinal categories. The primary outcome variables were the initial postoperative occlusion achieved at 5 weeks postoperatively (T2) and that maintained long-term more than 2 years after surgery (T4). Six occlusion parameters were assessed: overjet, overbite, coincidence of dental midlines, Angle classification, molar vertical, and transverse positions. A second outcome variable was the facial esthetic results. Photographs were analyzed to document 7 facial contour characteristics. RESULTS: Forty subjects met the inclusion criteria. Their age at surgery averaged 32 years (range 13 to 63). The study included 25 females (63%). The findings confirmed that the occlusion after initial surgical healing (T2) met the objectives for all parameters in 39 of the 40 patients (98%). Most patients (35 of 40; 88%) achieved and maintained a favorable occlusion for each parameter in the long-term (mean 5 years, 3 months). Subjects requiring counterclockwise rotation of the maxillomandibular complex were more likely to a have recurrent anterior open bite in the long-term. Facial contour deformities on presentation included weak chin (80%), deep labiomental fold (90%), everted lower lip (100%), short neck-to-chin length (88%), obtuse neck-to-chin angle (85%), weak mandible angles (93%), and "bunching" of the neck soft tissues (85%). Before surgery, 88% of the subjects exhibited a minimum of 5 of the 7 facial deformities. Correction of all 7 facial deformities was confirmed in 86% of the subjects in the long-term. CONCLUSIONS: Most PMD subjects achieved and maintained a corrected occlusion in the long-term. In the untreated subjects, a "facial type" was identified. Orthognathic surgery proved effective in correcting the associated facial dysmorphology in most patients.

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PURPOSE: The purpose of this study was to document the malocclusion and facial dysmorphology in patients with primary maxillary deficiency (PMD) and chronic obstructive nasal breathing before treatment and the outcomes after bimaxillary orthognathic, genioplasty, and intranasal surgery. MATERIALS AND METHODS: A retrospective cohort study of patients with PMD undergoing bimaxillary orthognathic, chin, and intranasal surgery was implemented. The predictor variables were grouped into demographic, anatomic, operative, and longitudinal follow-up categories. The primary outcome variables were the initial postoperative occlusion achieved (T2; 5 weeks postoperatively) and that maintained long-term (T3 or T4; >2 years after surgery). Six occlusion parameters were assessed: overjet, overbite, coincidence of dental midlines, Angle classification, and molar vertical and transverse positions. A second outcome variable was facial esthetic results. Photographs were analyzed to document 7 facial contour characteristics. RESULTS: Sixty-six patients met the inclusion criteria. Age at operation averaged 22 years (15 to 55 yr). The study included 18 women (27%). Most patients (57 of 66; 86%) achieved and maintained a favorable occlusion for each parameter studied long-term (mean, 5 yr). The need for a 3-segment Le Fort I was strongly associated with long-term posterior malocclusion. Facial dysmorphology before surgery included the appearance of a prominent chin (56%), flat labiomental fold (61%), prominent lower lip (88%), prominent nose (77%), sunken midface (100%), flat cheekbones (82%), and recessed upper lip (73%). Before surgery, 82% of patients exhibited at least 5 of the 7 key facial contour deformities. Correction of all 7 facial contour deformities was confirmed in 92% of patients in the long-term. In 8% of patients, an overly prominent-appearing chin persisted. CONCLUSION: Using orthognathic techniques, most patients with PMD achieved and maintained a corrected occlusion long-term. In unoperated patients, a "facial esthetic type" was identified. Bimaxillary orthognathic and chin surgery proved effective in correcting associated facial dysmorphology in most patients.

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PURPOSE: The purpose of this study was to document malocclusion and facial dysmorphology in a series of patients with long face (LF) and chronic obstructive nasal breathing before treatment and the outcomes after bimaxillary orthognathic, osseous genioplasty, and intranasal surgery. MATERIALS AND METHODS: A retrospective cohort study of patients with LF undergoing bimaxillary, chin, and intranasal (septoplasty and inferior turbinate reduction) surgery was implemented. Predictor variables were grouped into demographic, anatomic, operative, and longitudinal follow-up categories. Primary outcome variables were the initial postoperative occlusion achieved (T2; 5 weeks after surgery) and the occulsion maintained long-term (>2 years after surgery). Six key occlusion parameters were assessed: overjet, overbite, coincidence of dental midlines, canine Angle classification, and molar vertical and transverse positions. The second outcome variable was the facial esthetic results. Photographs in 6 views were analyzed to document 7 facial contour characteristics. RESULTS: Seventy-eight patients met the inclusion criteria. Average age at surgery was 24 years (range, 13 to 54 yr). The study included 53 female patients (68%). Findings confirmed that occlusion after initial surgical healing (T2) met the objectives for all parameters in 97% of patients (76 of 78). Most (68 of 78; 87%) maintained a favorable anterior and posterior occlusion for each parameter studied long-term (mean, 5 years 5 months). Facial contour deformities at presentation included prominent nose (63%), flat cheekbones (96%), flat midface (96%), weak chin (91%), obtuse neck-to-chin angle (56%), wide lip separation (95%), and excess maxillary dental show (99%). Correction of all pretreatment facial contour deformities was confirmed in 92% of patients after surgery. Long face patients with higher preoperative body mass index levels were more likely to have residual facial dysmorphology after surgery (P = .0009). CONCLUSION: Using orthognathic surgery techniques, patients with LF dentofacial deformity achieved the planned occlusion and most maintained the corrected occlusion long-term. In unoperated patients with LF, a "facial esthetic type" was identified. Orthognathic surgery proved effective in correcting associated facial dysmorphology in most patients.

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INTRODUCTION: The Herbst appliance has been used in the treatment of Class II malocclusions with deficient mandibles. Various protocols, including different durations of the orthopedic treatment phase and stepwise advancement of the mandible, have been advocated for increasing the orthopedic effects. The objective of this study was to investigate the skeletal and dental changes in patients treated with a reinforced banded Herbst appliance for an extended duration and fixed appliance therapy. METHODS: The study group consisted of 30 patients (16 boys, 14 girls; mean age, 12.3 ± 2.5 years) with Class II Division 1 malocclusions who were successfully treated with the new Herbst protocol followed by fixed appliances. Lateral cephalometric radiographs were taken before treatment, at the completion of Herbst treatment, and after removal of fixed appliances. The average treatment times were 1.5 ± 0.7 years for the Herbst treatment and 1.8 ± 0.5 years for the fixed appliances. A control Class II sample from the Bolton-Brush study was used to subtract growth from treatment changes to determine the appliance effect. Data were analyzed using analysis of variance and the Tukey-Kramer test. RESULTS: After the Herbst treatment, the incisal relationships of all subjects had been overcorrected to end-to-end relationships. Overjet was reduced by 7.2 mm after subtracting changes from growth. The skeletal contribution was 2.5 mm (35%), and the dental contribution was 4.7 mm (65%). The molar relationship was overcorrected to a more Class I relationship by 7.5 mm. The Wits appraisal was improved by 4.2 mm. Vertically, overbite was decreased by 3.3 mm. The maxillary and mandibular molars were extruded by 1 mm. The occlusal plane rotated clockwise by 5° with little change in the mandibular plane angle. After the treatment with fixed appliances, the overjet correction was maintained at 7.6 mm. The skeletal contribution was 2.9 mm (38%), and the dental contribution was 4.7 mm (62%). The molar relationship was corrected to a Class I relationship by 5.9 mm. The Wits appraisal was improved by 3.2 mm. Vertically, overbite was decreased by 4.2 mm. The maxillary and mandibular molars were extruded by 0.3 and 0.8 mm, respectively. The occlusal plane rotated clockwise by 1.2° with little change in the mandibular plane angle. CONCLUSIONS: Doubling the usual orthopedic treatment time with the reinforced Herbst appliance followed by fixed appliance therapy was effective in correcting Class II Division 1 malocclusions with excess overjet and overbite. In this sample of successfully treated patients, most changes after Herbst and fixed appliance therapy were dentoalveolar (62%). However, the skeletal changes attained in the orthopedic phase of treatment were maintained after fixed appliance therapy.

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AIM: To evaluate and compare the anteroposterior relationship of the maxillary central incisors to the forehead in white male adults with harmonious profiles and white male adult orthodontic patients. METHODS: Photographs of 101 white male adults with good facial harmony (control sample) were compared with photographs of 97 white male adults seeking orthodontic treatment (study sample). All were profile images with the maxillary central incisors and foreheads in full view. The images were imported into an image editing software program, resized, and rotated to the upright head position. Reference lines were constructed to assess the anteroposterior positions of the maxillary central incisors and forehead inclinations. RESULTS: In the control sample, the maxillary central incisors were positioned between the forehead facial axis (FFA) point and glabella in 91%, posterior to the FFA point in 8%, and anterior to the glabella in <1%. The position of the maxillary central incisors was moderately correlated with forehead inclination (r² = 0.37). In the study sample, the maxillary central incisors were positioned between the FFA point and glabella in 34%, posterior to the FFA point in 59%, and anterior to the glabella in 7%. Maxillary central incisor position and forehead inclination were strongly correlated (r² = 0.53). The anteroposterior maxillary incisor position relative to the forehead between the control and study groups was significantly different (P < .0001). In addition, the forehead inclination between the control and study group was significantly different (P < .05). CONCLUSION: The forehead is an important landmark for anteroposterior maxillary incisor positioning for adult white male patients seeking improved facial harmony.

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