The specialty of orthodontics is being formalized in Belgium. The opportunity is given to those with extensive orthodontic experience to pass an examination to receive the title. Specifically, the eligible groups for the title are:
1. Those with university training.
2. GP who practiced orthodontics exclusively for 6 years before June 2003.
3. GP's who practiced orthodontics exclusively since at least June 2006 AND succeeding on the examination.
Here are details of the examination: (Skip to Downloads)
20 Case Presentations: to cover at least the malocclusions listed
* Angle classification II/1 with SN/GoGn +37°.
* Malocclusion started in the mixed dentition and finished in the permanent dentition, starting records needed.
* Angle classification I with dento-alveolar protrusion, or open bite, or deep bite, or lots of crowding (not specified how much crowding is meant by “lots”) or with eruption problems that make an orthodontic treatment necessary
* Angle classification II/2 malocclusion
* Angle classification II/1 with lots of crowding in the lower arch
* A malocclusion needing surgery
* Malocclusion with a big sagittal and/or vertical discrepancy and/or a transverse discrepancy.
- Start and finishing records including study models, panoramic x-ray, and cephalometric x-ray.
- Intra-oral and extra-oral pictures were encouraged, but not required.
- Each case had to be written up according to a certain protocol.
- Treatment options must be listed and defense must be made why a certain treatment plan was chosen.
- A month-by-month report of the treatment
- Overlays of the stable structures
- A critical report about the case
Theoretical: The board gave a set of patient records to diagnose the case, after which the diagnosis was to be defended before 2 examiners. Theoretical questions were asked of the candidate.
The case given to Chantal was a full dental class II, no lower crowding with a perfect arch, skeletal class II (ANB +6.5) and wits 5.5 with a retrusive mandible. There was an impacted upper cuspid (not severe) with root resorption on the adjacent lateral incisor. The case would normally have been a first bicuspid extraction case, but because of the root resorption of the lateral incisors, Chantal chose to extract the upper lateral incisors (upper 2 extraction with class II molar finish).
Besides the ceph, panoramic, and extra-oral pictures, a wrist x-ray was provided. The boy was 16 years old, but the growth plates were not yet closed, a sesamoid was present. The question was asked where the boy was on the growth curve. Chantal added the wrist information with cervical vertebra being CVM stage 4, after which she discussed the growth curve from birth to mature age, the relative growth, and the absolute growth curve.
Other questions included:
- How to handle the TSD when extracting the lateral incisors
- How to handle the tipping of the canine and what was to be done when the root of the canine was too far distal
- Was anything to be done about the retrusive mandible, and if so, what could be done
On the retrusive mandible question, Chantal answered “no”, that there was no way to make mandibles grow, and that this statement is supported by the literature. [note: One of the examiners had previously taught ortho, claiming activators could make mandibles grow, but he had changed his mind on this]
Other issues not specifically asked, but should be known:
- Early expansion of upper arches to correct crossbite is not considered the way to manage these cases. The university people there feel that natural wideing of the upper arch happens anyway as long as the deciduous canines are in (uppers following widening of the lower).
- How to limit the vertical forces on a lower 7 that needs to be uprighted. Possibly they wanted to hear is to put an uprighting look in the middle between the brackets so there are only moments.
Case Defense: During the theoretical examination, 2-3 examiners were reviewing the case presentations. Each candidate was then called in to defend their cases. Questions give to Chantal included,
- Bi-protrusive case with lips open at rest (case 1). The examiners said her diagnosis was wrong. She defended that first bicuspid extractions were the only sensible treatment option besides possibly orthognathic surgery. Confrontation.
- Adult case with crowding and missing 44 (case 6). The examiners claimed she should not have extracted the remaining 3 bicuspids, that only extracting tooth 14 (+missing 44) would have been enough. Chantal replied that she always treats to a symmetrical arch and that extracting unilaterally is asking for trouble with arch shape and keeping the midlines centered.
- Why was she not using bonded lingual retainers? Chantal replied that a stabile result depends on many factors, including keeping the incisors in the starting position, correcting rotations early in treatment, and by preference to over-correct the rotations, stripping if needed, adding a fiberotomy if needed, and then retaining these teeth most of the time with a clear overlay retainer. This retainer gives her the opportunity to strip later in retention if some recrowding would reappear due to the natural decrease in archlength up to age 18, supported by the literature. A bonded lingual retainer does not give this possibility, will not last forever either, and is not as good for periodontal health as flossing is not possible.
- Explain late (re)crowding? Chantal explained the change in lip tension and crowding. 3rd molars should be removed for reasons other than to prevent recrowding, and that this is a multi-factoral matter, not to be loading a patient with difficult extractions. She stated that she was waiting for the day when someone has the answer to avoid instability in retention.
- Why were you not using activators? Chantal replied that activators do not make mandibles grow, that the literature supports this, and that she believed that very good results could be achieved using a headgear. One examiner got hostile, asking if she was implying that he and others still using activators do not know what they are doing? Chantal explained that she had used activators in the past and that in certain situations she still uses them (eg. Bionator for habit control at a young age), but that she had a few problem cases, especially with boys because of the timing (growth spurt later than girls), so she prefers using headgear. The examiner replied that headgear also requires cooperation? Chantal defended that this was true, but with a headgear they can still talk normal and when they take it out, it is not such a slimy situation. She told them that they can see that she gets very good results with headgear, that a very small part comes from limiting growth of a maxilla and it is her personal belief that wearing a headgear can mess up the occlusal interdigitation, allowing freedom for the mandible to grow. If nature did not plan for the mandible to grow, then this is too bad, but quite often this is what she sees.
- If you are so good with headgears, then why did you not give a headgear to one of the cases treated with surgery (case 15)? Chantal replied that this was a TMD patient and to keep the treatment short and because of the profile (concave), surgery was chosen for the best facial esthetics. Examiner replied that headgear is not effecting the joint? Chantal agreed, but if headgear cooperation changed during treatment that I needed to give her elastics to keep the class I and this could become a huge problem for a TMD patient. This treatment was approved by the patient and oral surgeon.
- What kind of anchorage and the mechanics used in the pre-surgical ortho (case 14)? The examiners claimed she should have retracted the incisors more to close the space than to advance the molars. Chantal replied that this would have ruined the midline which was well centered at the start. The ceph and overlays showed this patient was treated to almost ideal, so where was the problem? She said this was a tough case to treat and she was happy with the result. The patient is functioning well and looks much better. One of the 3 examiners agreed. The examiner wanted to know who the oral surgeon Chantal worked with and if she had experience with implants for anchorage. Chantal replied no, but this was her next step in orthodontics.
- The examiners gave no comments on the well fitting occlusions nor the over-correction of rotations that Chantal pointed out on the IP cases.
Final remarks: All the cases finished class I, which was a criteria for selection as well as the nearly ideal incisor inclinations. It was very important to have nicely presented cases to make a good impression. The examiners wanted to see that you worked hard. There was not one single comment on the 5 IP cases.
Chantal “feels” that the IP cases were generally much easier, even though the 5 IP cases in this sample were in the early days of diagnosis, not incorporating the full principles of IP, and not using 18x25HA to the full advantage. Generally speaking, Chantal feels that IP cases treat to completion 6 months faster when compared to straight wire, although this is not obvious in this sample. She has the luxury of past experience to make a comparison possible.
Assistant/Doctor time: No assistant was employed during the time that these patients were treated. The adjusted doctor times for an assistant assume that the assistant cannot work in the patients’ mouth, which is law in . If an assistant could perform procedures in the patients’ mouth, then the doctor times would reduce another 50-100%.
Cephalometric Measurements: There are some cephalometric measurements that might not be understood by POS readers, so here is a quick explanation
1. GoGnSN: This measurement is similar to FMA, but in the Steiner Analysis. This measurement which describes skeletal open vs closed bite, is the angle measured between the SN line and the mandibular plane, measured between Gnathion and Gonion. Gonion is on the most convex curvature of the inferior-posterior ramus.
2. +1/NA: This is the upper central incisor (+1) as measured from the Nasion-A point reference line. The angle defines the upper incisor inclination (similar to upper 1SN) with a larger number being more proclined, smaller being more retroclined. The millimeter measurement defines the antero-posterior position (similar to upper 1APo and upper 1 to A perpendicular) with larger numbers being more protrusive, smaller more retrusive.
3. -1/NB: This is the lower incisor (-1) as measured from the Nasion-B point reference line. The angle defines the lower incisor inclination (similar to lower 1MP), with larger numbers being more proclined, smaller numbers more retroclined. The millimeter measurement is used in the McGann analysis, and defines the antero-posterior position.
Specialty Case Downloads:
||Class II, div.1 protrusion with lip incompetency. Male, age 12.5 years, extracted 4s upper and lower
|| Size: 3.2MB
||Class I crowded, class III skeletal. Phase I+II non-extraction Female, age 12
|| Size: 4.39MB
||Phase I+II non-extraction of class I case with retruded incisors and impacted cuspid retrieval
|| Size: 4.32MB
||Phase I+II non-extraction of class I case with mild crowding
|| Size: 3.6MB
||Class I non-extraction with mild crowding
|| Size: 3.72MB
||Class I deep bite with missing tooth 44, extraction of first bicuspids, Female age 15 yr, 10 mo.
|| Size: 5.06MB
||Class II division 2, non-extraction with headgear, Male age 12
|| Size: 4.76MB
||Phase I+II serial extraction of upper 4s, LR5, LL4. Male age 9 year 8 month
|| Size: 4.29MB
||Class II division 2, non-extraction, Female age 13
|| Size: 3.39MB
||Class II, division 2, extraction of upper 7s, cervical headgear, Female age 12
|| Size: 3.16MB
||Phase I+II Class II, division 1, deep bite, unilateral crossbite, treated non-extraction. Female age 11 year 3 months.
|| Size: 3.07MB
||Class II division 1, Extraction of upper 6s, Male age 13.5.
|| Size: 3.17MB
||Class II division 1, impacted upper right cuspid, missing upper 2s. Closed the upper 2 spaces, class II molar finish. Female age 14.
|| Size: 3.17MB
||Class II division 1, Mandibular advancement surgery, periodontal disease, missing first bicuspids. Female age 33
|| Size: 3.87MB
||Class II division 1, Maxillary + Mandibular surgery, with Genioplasty. Non-extraction orthodontics, Age 14 year 4 month female
|| Size: 4.08MB
||Class II division 1, unilateral upper 7 extraction with headgear, Male age 14.
|| Size: 3.38MB
||Class II division 1, phase I+II, non-extraction with headgear, Female age 12
|| Size: 6.18MB
||Class II division 1, first bicuspid extraction, Female age 11
|| Size: 5.29MB
||Class I, phase I+II, non-extraction with rapid expansion, Female age 14
|| Size: 3.7MB
||Class II, division 1, extract upper 7s, Male age 11.8
|| Size: 5.55MB
||Writeup (case 20)
|| Size: 3.26MB
|| Size: 3.26MB