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 L, Rita Yeh, Jade Chen. Ron Tseng, Winnie L, 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 Newtons 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.

Newtons 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 didnt think itd
turn out well. Its 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 ortho-
and implant-combined treatment, International Journal of Orthodontics and Implantology (IJOI). Each issue is about 100
pages long and distributed internationally.

iii
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. Its 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 canall be far
better orthodontists!

iv
Feedback on Orthodontics

From this book we can gain a detailed understanding of Im 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 Dr. Mike Steffens, Edmond, Oklahoma, USA

A great idea! The future of textbooks will go this way. Just brilliant, amazing! Thank you for the contribution.
Dr. Javier. Prieto, Segovia, Spain Dr. Errol Yim, Honolulu, Hawaii, USA

v
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

vi
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 viii
Preface
As orthodontists we have long been searching for the most efficient way to learn orthodontics. Irregardless ones
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.

x
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 worked-
up 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

xii
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.

xiii
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 dierence.

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 Ive 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 couldnt be done without an excellent team of Beethovens 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 Je Dean.

xiv
Ten years ago Dr. Parks MIA team, furthered the development and ocially 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 couldnt 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 cant 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

xv
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 Steen, Rungsi Thavarungkul, Tucker Haltom, Larry White, Baldwin Marchack and Stephen Wallace.

Last but not the least, I cant 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 Newtons 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.

xvi
 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
Collectively, the ABO (DI, OGS) and the Indiana CCA
outcomes, relative to the clinicians objectives, by
methods are effective tools for quality assessment of
assessing cephalometric tracings, measuring arch-widths
clinical orthodontics.3, 7-9 ,13-14, 16 This article summarizes
on casts, and determining the overall quality of the case
the methods and provides references for the detailed
records. The DI, OGS and CMF methods are designed to
application of the techniques.
determine if case records presented by a candidate meet
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
21
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
Fig. 2 Objective grading system form
original can be downloaded from the ABO website.1 The
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

24
25
26
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 data-
entry 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 The ABO Objective Grading System for scoring
dental casts and panoramic radiographs contains
assessment of the finished orthodontic alignment. eight criteria: alignment, marginal ridges, buccolin-
gual inclination, occlusal relationships, occlusal
DI has proven to be an effective indicator of
contacts, overjet, interproximal contacts, and root
malocclusion complexity (severity) for a wide variety of 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, A. True
periodontium preservation, and growth management.
B. False
Collectively, the DI, OGS and CCA methods provide a
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

28
5 References

1. American Board of Orthodontics Website: http:// 6. Costalos PA, Sarraf K, Cangialosi TJ, Efstratiadis S. Evaluation of
www.americanboardortho.com, accessed July22, 2009. the accuracy of digital model analysis for the American Board of
Orthodontics objective grading system for dental casts. Am J
2. Abei Y, Nelson S, Amberman BD, Hans MG. Comparing
Orthod Dentofacial Orthop 2005;128:624-629.
orthodontic treatment outcome between orthodontists and
general dentists with the ABO index. Am J Orthod Dentofacial 7. Deguchi T, Honjo T, Fukunaga T, Miyawaki S, Roberts WE,
Orthop 2004;126:544-548. Takano-Yamamoto T. Clinical assessment of orthodontic
outcomes with the peer assessment rating, discrepancy index,
3. Campbell CL, Roberts WE, Hartsfield JK, Jr., Qi R. Treatment
objective grading system, and comprehensive clinical
outcomes in a graduate orthodontic clinic for cases defined by the
assessment. Am J Orthod Dentofacial Orthop 2005;127:434-443.
American Board of Orthodontics malocclusion categories. Am J
Orthod Dentofacial Orthop 2007;132:822-829. 8. Hsieh TJ, Pinskaya Y, Roberts WE. Assessment of orthodontic
treatment outcomes: early treatment versus late treatment. Angle
4. Casko JS, Vaden JL, Kokich VG, Damone J, James RD,
Orthod 2005;75:162-170.
Cangialosi TJ et al. Objective grading system for dental casts and
panoramic radiographs. American Board of Orthodontics. Am J 9. Knierim K, Roberts WE, Hartsfield J, Jr. Assessing treatment
Orthod Dentofacial Orthop 1998;114:589-599. outcomes for a graduate orthodontics program: follow-up study
for the classes of 2001-2003. Am J Orthod Dentofacial Orthop
5. Cook DR, Harris EF, Vaden JL. Comparison of university and
2006;130:648-655, 655 e641-643.
private-practice orthodontic treatment outcomes with the
American Board of Orthodontics objective grading system. Am J 10.Murakami K, Deguchi T, Hashimoto T, Imai M, Miyawaki S,
Orthod Dentofacial Orthop 2005;127:707-712. 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 17.Wes Fleming J, Buschang PH, Kim KB, Oliver DR. Posttreatment
e421-426. occlusal variability among angle Class I nonextraction patients.
Angle Orthod 2008;78:625-630.
11.Nett BC, Huang GJ. Long-term posttreatment changes measured
by the American Board of Orthodontics objective grading system. 18.Riolo, M. L., S. E. Owens, et al. (2005). "ABO resident clinical
Am J Orthod Dentofacial Orthop 2005;127:444-450; quiz 516. outcomes study: case complexity as measured by the discrepancy
index." Am J Orthod Dentofacial Orthop 127 (2): 161-3.
12.Park Y, Hartsfield JK, Katona TR, Eugene Roberts W. Tooth
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.

30
6 CCA Scoring Criteria

CCA Scoring Criteria - no more than 5 points scored for each category

1.# Compliance: Failures, Poor Oral Hygiene, Tx Cooperation# (5)________

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

2.# Records Quality:# (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
eective presentations.

In addition to teaching and private practice, he also founded Newtons 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.

xxxiv
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 Jeery 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.

xxxv
Dear Friends, my name is Chris Chang from Taiwan. Im so excited about this ebook and how Apples 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
atmechanicalengineering 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 somany cases non-
surgically, 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 aliate 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 aparticularsculpture 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 hasbeen 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 multi-
media presentations to train yourself in advanced methods of orthodontics. Thank you very much.
xxxvii
xxxviii