Orthodontics

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Orthodontia, also called orthodontics and dentofacial orthopedics, is a specialty field of dentistry that deals primarily with malpositioned teeth and the jaws: their diagnosis, prevention and correction. An orthodontist is a specialist who has undergone special training in a dental school or college after they have graduated in dentistry. The field was established by the efforts of pioneering orthodontists such as Edward Angle and Norman William Kingsley.

Video Orthodontics

Etymology

"Orthodontics" is derived from the Greek orthos ("correct", "straight") and -odont- ("tooth").

Maps Orthodontics

History

The history of orthodontics has been intimately linked with the history of dentistry for more than 2000 years. Dentistry had its origins as a part of medicine. According to the American Association of Orthodontists, archaeologists have discovered mummified ancients with metal bands wrapped around individual teeth. Malocclusion is not a disease, but abnormal alignment of the teeth and the way the upper and lower teeth fit together. The prevalence of malocclusion varies, but using orthodontic treatment indices, which categorize malocclusions in terms of severity, it can be said that nearly 30% of the population present with malocclusions severe enough to benefit from orthodontic treatment.

Orthodontic treatment can focus on dental displacement only, or deal with the control and modification of facial growth. In the latter case it is better defined as "dentofacial orthopedics". In severe malocclusions that can be a part of craniofacial abnormality, management often requires a combination of orthodontics with headgear or reverse pull facemask and / or jaw surgery or orthognathic surgery.

This often requires additional training, in addition to the formal three-year specialty training. For instance, in the United States, orthodontists get at least another year of training in a form of fellowship, the so-called 'Craniofacial Orthodontics', to receive additional training in the orthodontic management of craniofacial anomalies.

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Methods

Typically treatment for malocclusion can take around 2 years to complete, with braces being altered slightly every 6 to 8 weeks by the orthodontist. There are multiple methods for adjusting malocclusion, depending on the needs of the individual patient. In growing patients there are more options for treating skeletal discrepancies, either promoting or restricting growth using functional appliances, orthodontic headgear or a reverse pull facemask. Most orthodontic work is started during the early permanent dentition stage before skeletal growth is completed. If skeletal growth has completed, orthognathic surgery can be an option. Extraction of teeth can be required in some cases to aid the orthodontic treatment. Starting the treatment process of overjets and prominent upper teeth in children rather than waiting until the child has reached adolescence has been shown to reduce damage to the lateral and central incisors. However the treatment outcome does not differ.

Functional appliances

When there is a maxillary overjet, or Class II occlusion, functional appliances can be used to correct the occlusion. These may be fixed or removable. Fixed dental braces are wires that are inserted into brackets secured to the teeth on the labial or lingual surface (lingual braces) of teeth. Other classes of functional appliances include removable appliances and over the head appliances, and these functional appliances are used to redirect jaw growth. Post treatment retainers are frequently used to maintain the new position of the dentition.

During fixed orthodontic treatment, metal wires are held in place by elastic bands on orthodontic brackets (braces) on each tooth and inserted into bands around the molars. The wires can be made from stainless steel, nickel-titanium (Ni-Ti) or a more aesthetic ceramic material. Ni-Ti is used as the initial arch wire as it has good flexibility, allowing it to exert the same forces regardless of how much it has been deflected. There is also heat activated Ni-Ti wire which tightens when it is heated to body temperature. The arch wires interact with the brackets to move teeth into the desired positions.

Fixed orthodontic appliances aid tooth movement, and are used when a 3-D movement of the tooth is required in the mouth and multiple tooth movement is necessary. Ceramic fixed appliances can be used which more closely mimic the tooth colour than the metal brackets. Some manufacturers offer self-litigating fixed appliances where the metal wires are held by an integral clip on the bracket themselves. These can be supplied as either metal or ceramic.

The surfaces of the teeth are etched, and brackets are attached to the teeth with an adhesive that is durable enough to withstand the orthodontic forces, but is able to be removed at the end of treatment without damaging the tooth. Currently there is not enough evidence to determine whether self-etch preparations or conventional etchants cause less decalcification around the bonding site and if there is a difference between them in bond failure rate. The bonding material must also adhere to the surface of the tooth, be easy to use and preferably protect the tooth surface against caries (decay) as the orthodontic appliance becomes a trap for plaque. Currently a resin/matrix adhesive which is command light cured is most commonly used. This is similar to composite filling material.

Anchorage for the appliance prevents unwanted movement of teeth and it can come from the headgear worn, the palate, or surgical implants.

For young patients with mild to moderate Angle Class III malocclusions (prognathism), a functional appliance is sufficient for correction. Examples of functional appliances are: facemask, chin-cup, tandem traction bow or headgear. As the malocclusion increases, orthognathic surgery might be required. This treatment comes in three stages. Prior to surgery there is orthodontic treatment to align teeth into their post-surgery occlusion positions. The second stage is surgery such as a mandibular step osteotomy or sagittal/bilateral sagittal split osteotomy depending on whether one or both sides of the mandible are affected. The bone is broken during surgery and is stabilised with titanium plates and screws, or bioresorbable plates to allow for healing to take place. The third stage of treatment is post-surgical orthodontic treatment to move the teeth into their final positions to ensure the best possible occlusion.

A posterior crossbite malocclusion may be corrected using the quad helix appliance or removable appliances during the early mixed dentition stage (eight to 10 years), and more research is required for determining whether any intervention provides greater results than any other for later stages of dentition development. These crossbites are when the maxillary teeth or jaw is narrower than the mandibular, and can occur unilaterally or bilaterally. . Treatment involves the expansion of the maxillary arch to restore functional occlusion, which can either be 'fast' at 0.5mm per day or 'slow' at 0.5mm per week. Palatal expansion can be achieved using either fixed or removable appliances. Banded maxillary expansion involves metal bands bonded to individual teeth which are attached to braces, and bonded maxillary expansion is an acrylic splint with a wire framework attached to a screw in the palatal mid-line, which can be turned and opened to expand the maxilla.

Removable functional appliances are useful for simple movements and can aid in altering the angulation of a tooth: retroclining maxillary teeth and proclining mandibular teeth; help with expansion; and overbite reduction.

Headgear works by applying forces externally to the back of the head, moving the molar teeth posteriorly (distalising) to allow space for the anterior teeth and relieving the overcrowding or to help with anchorage problems.

The facemask aims to pull maxillary teeth and jaw forward and downwards to meet the mandible through a balanced force applied to the upper teeth. The mask rests on the forehead and chin of the wearer, and connects to the maxillary teeth with elastic bands.

Some removable appliances have a flat acrylic bite plane to allow full disocclusion between the maxillary and mandibular teeth to aid in movement during treatment. An example of this is the Clark Twin Block. This design has two blocks of acrylic which disocclude the teeth and protrude the mandible. It is used to treat Class II malocclusion.

Vacuum-formed aligners such as Invisalign consist of clear, flexible, plastic trays that move teeth incrementally to reduce mild overcrowding and can improve mild irregularities and spacing. They are not suitable for use in complex orthodontic cases and cannot produce body movement. They are worn full time by the patient apart from when eating and drinking. A large benefit of these types of orthodontic appliance are that they suitable for use when the patient has porcelain veneers: as metal brackets cannot be bonded to the veneer surface.

Adjunctive therapy

Adjunctive surgical and non surgical therapy have been researched as options to help reduce the duration of orthodontic treatment. Surgical intervention such as alveolar decortication, and corticision have been used in conjunction with orthodontic treatment to reduce the time spent in functional appliances, but more research is required into the possible effects of the surgery. Non-surgical therapy involves the use of vibrational forces during treatment, but it has not been shown whether this significantly reduces the treatment time, orincreases the comfort for the patient.

Extensive research has been done proving the effectiveness of functional appliances, but maintaining the results is important once the active treatment phase has completed.

Post treatment

After orthodontic treatment has completed, there is a tendency for teeth to return, or relapse, back to their pre-treatment positions. Over 50% of patients have some reversion to pre-treatment positions within 10 years following treatment. To prevent relapse, the majority of patients will be offered a retainer (orthodontics) once treatment has completed, and will benefit from wearing their retainers. Retainers can be either fixed or removable. Removable retainers will be worn for different periods of time depending on patient need to stabilise the dentition. Fixed retainers are a simple wire fixed to the labial surface of the incisors using dental adhesive and can be specifically useful to prevent rotation in incisors. Other types fixed retainers can include labial or lingual braces, with brackets fixed to the teeth.

Removable retainers can include one known as a Hawley retainer, made with an acrylic base plate and metal wire covering the canine to canine region. Another form of removable retainer is the Essix retainer which is made from vacuum formed polypropylene or polyvinylchloride and can cover all the dentition.

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Diagnosis and treatment planning

In diagnosis and treatment planning, the orthodontist must (1) recognize the various characteristics of a malocclusion or dentofacial deformity; (2) define the nature of the problem, including the etiology if possible; (3) design a treatment strategy based on the specific needs and desires of the individual; and (4) present the treatment strategy to the patient in such a way that the patient fully understands the ramifications of his/her decision.

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Orthodontic Indices

Orthodontic indices are one of the few tools that are available for orthodontists to grade and assess malocclusion. Orthodontic indices can be useful for epidemiologist to analyse prevalence and severity of malocclusion in any population.

Angle's Classification

Angle's Classification is devised in 1899 by father of Orthodontic, Dr Edward Angle to describe the classes of malocclusion, widely accepted and widely used since it was published. Angle's Classification are based on the relationship of the mesiobuccal cusp of the maxillary first molar and the buccal groove of the mandibular first molar. Angle's Classification describes 3 classes of malocclusion:

• Class I: The molar relationship of the occlusion is normal or as described for the maxillary first molar, with malocclusion confined to anterior teeth
• Class II: The retrusion of the lower jaw with distal occlusion of the lower teeth (or in other words, the maxillary first molar occludes anterior to the buccal groove of the mandibular first molars
  • Class II div 1: class II relationship with proclined upper central incisors (overjet)
  • Class II div 2: class II relationship with lingual inclination of upper central incisors (retrocline) and upper lateral incisors overlapping the centrals
• Class III: The protrusion of the lower jaw with mesiobuccal cusp of maxillary first molar occluding posterior to the buccal groove of the mandibular first molar, with lingually inclined lower incisors and cuspids

Angle's classification only considers anteroposterior deviations in the sagittal plane while malocclusion is a three dimensional problem (sagittal,transverse and vertical) rather than two dimensional as described in Angle's classification Angle's classification also disregards the relationship of the teeth to the face.

Massler and Frankel's index recording the number of displaced/rotated teeth

Introduced in 1951 by Massler & Frankel to produce a way to record the prevalence of malocclusion which will satisfy 3 criteria: simple, accurate and applicable to large groups of individual; yield quantitative information that could be statistically analysed; reproducible so that results are comparable. This index uses individual teeth as unit of occlusion instead of a segment of the arch. Each tooth is examined to determine whether it is in correct occlusion or it is maloccluded.

The total number of maloccluded teeth is the counted and recorded. Each tooth is examined from two different aspects: occlusal aspect and then the buccal and labial surfaces with the exclusion of third molars. Tooth that is not in perfect occlusion from both occlusal aspect (in perfect alignment with contact line) and buccal aspect (in perfect alignment with plane of occlusion and in correct interdigitation with opposing teeth) is considered as maloccluded. Each maloccluded tooth is given a value of 1 while tooth in perfect occlusion is given a score of 0. A score of 0 will indicate a perfect occlusion; score of more than 10 would be classified as sufficient severity that would require orthodontic treatment; score between 1 to 9 would be classified as normal occlusion in which no orthodontic treatment is indicated.

However, while this index are simple, easy and able to provide prevalence and incidence data in populations group, there are some major disadvantage with this index: primary dentition, erupting teeth and missing teeth are left out in the scoring system and difficulties in judging conformity of each tooth to an ideal position in all planes.

Malignment Index

Introduced in 1959 by Lawrence Vankirk and Elliott Pennell. This index requires the use of a small plastic, gauge-like tool designed for assessment. Tooth rotation and displacement are measured.

The mouth are divided into 6 segment, and is examined in the following order: maxillary anterior, maxillary right posterior, maxillary left posterior, mandibular anterior, mandibular right posterior and mandibular left posterior. The tool is superimposed over the teeth for the scoring measurement, each tooth present is scored 0, 1 or 2.

2 types of malalignment are being measured, rotation and displacement. Rotation is defined as angle formed by the line projected through contact areas of observed tooth and the ideal arch line. Displacement is defined as both of the contact areas of the tooth are displaced in the same direction from the ideal alignment position.

• Score of 0 represents ideal alignment with no apparent deviation from the ideal arch line.
• Score of 1 represents minor malalignment: rotation of less than 45º and displacement of less than 1.5mm
• Score of 2 represents major malalignment: rotation of more than 45º and displacement of more than 1.5mm

Handicapping Labiollingual Deviation Index (HLDI)

This index was proposed in 1960 by Harry L. Draker. HLDI was designed for identification of dento-facial handicap. The index is designed to yield prevalence data if used in screenings. Measurement taken are as following: cleft palate (all or nothing), severe traumatic deviation (all or none), overjet (mm), overbite (mm), mandibular protrusion (mm), anterior open bite (mm), labiolingual spread (measurement of tooth displacement in mm) HLD index is used in several states in the United States, with some modifications to its original form by the states that used them for determining orthodontic treatment need.

Occlusal Feature Index

Occlusal Feature Index is introduced by Poulton and Aaronson in 1961. The index is based on four primary features of occlusion that is important in orthodontic examination. The four primary features are as following:

• Lower anterior crowding (canine to canine area)
• Posterior cuspal interdigitation (right posterior premolar to molar area)
• Vertical overbite (measured by portion of lower incisor covered by upper central incisors when in occlusion)
• Horizontal overjet (measured between the labial surface of upper incisor to labial surface of lower incisor)

Occlusal Feature Index recognises malocclusion is a combination of the way teeth occlude as well as the position of the teeth relative to the neighbouring teeth. However, the scoring system is not sensitive enough for case selection for orthodontic purposes.

Malocclusion Severity Estimate (MSE)

Introduced in 1961 by Grainger. MSE measured 7 weighted and defined measurement:

• Overjet
• Overbite
• Anterior open bite
• Congenitally missing maxillary incisors
• First permanent molar relationship
• Posterior cross bite
• Tooth displacement (actual and potential)

MSE defined and outlined 6 syndromes of malocclusion:

1. Positive overjet and anterior open bite
2. Positive overjet, positive overbite, distal molar relationship and posterior crossbite with maxillary teeth buccal to mandibular teeth.
3. Negative overjet, mesial molar relationship and posterior crossbite with maxillary teeth lingual to mandibular teeth
4. Congenitally missing maxillary incisors
5. Tooth displacement
6. Potential tooth displacement

Despite being a relative comprehensive definition, there are a few shortcomings of this index, namely: the data is derived from a 12 years old patients hence might not be valid for deciduous and mixed dentitions, the score does not reflect all the measurement that were taken and accumulated and the absence of any occlusal disorder is not scored as zero. Grainger then revised the MSE index and published the revised version in 1967 and renamed the index to Treatment Priority Index (TPI).

Occlusal Index (OI)

Occlusal Index was developed by Summers in his doctoral dissertation in 1966, and the final paper was published in 1971. Based on Malocclusion Severity Estimate (MSE), OI attempted to overcome shortcoming of the MSE.

Summers devised different scoring scheme for deciduous, mixed and permanent dentition with 6 predefined stages of dental age:

1. Dental age 0 begins at birth, ending with eruption of first deciduous tooth.
2. Dental age 1 begins when stage 0 ended, ending with all deciduous teeth are in occlusion.
3. Dental age 2 begins when stage 1 ended, ends with eruption of first permanent tooth.
4. Dental age 3 begins when stage 2 ended and ends with all the permanent central, lateral incisors and first permanent molar are in occlusion.
5. Dental age 4 begins when stage 3 ended and ends with eruption of any permanent canines or premolar.
6. Dental age 5 begins when stage 4 ended and ends with all permanent canines and premolar are in occlusion.
7. Dental age 6 begins when all permanent canines and premolar are in occlusion.

Nine weighted and defined measurement being taken:

• Molar relation
• Overbite
• Overjet
• Posterior crossbite
• Posterior open bite
• Tooth displacement
• Midline relation
• Maxillary median diastema
• Congenitally missing maxillary incisors

Summers also defined 7 malocclusion syndromes which includes:

1. Overjet and openbite
2. Distal molar relation, overbite, overjet, posterior crossbite, midline diastema and midline deviation
3. Congenitally missing maxillary incisors
4. Tooth displacement (actual and potential)
5. Posterior open bite
6. Mesial molar relation, overjet, overbite, posterior crossbite, midline diastema and midline deviation
7. Mesial molar relation, mixed dentition analysis (potential tooth displacement) and tooth displacement.

Grade Index Scale for Assessment of Treatment Need (GISATIN)

Dental Aesthetic Index (DAI)

Treatment Priority Index (TPI)

Handicapping Malocclusion Assessment Record (HMAR)

Littles Irregularity Index

WHO/FDI - basic method for recording of malocclusion

Dental Aesthetic Index

Handicapping Labiollingual Deviation (HLD) (CalMOD)

Peer Assessment Rating Index (PAR)

This index was implemented in 1987 by the British Orthodontic Standard Working Party after 10 members of this party formulated this index over a series of 6 meetings

This index is a fast, simple and robust way of assessing the standard of orthodontic treatment that an individual orthodontist is achieving or trying to achieve rather than the degree of malocclusion and/or need for orthodontic treatment. However, it should have already been concluded that these patients should be receiving orthodontic treatment prior to the PAR index. The PAR index has also been used to assess whether clinicians are correctly determining the need for orthodontic treatment when compared with a calibrated examiner of malocclusion.

This type of index compares outcomes of orthodontic treatment as it primarily observes the results of a group of patients, rather than on an individual basis against results that they would expect. This type of testing occurs as there will always be a small number of individual patients in which the index results does not fully represent. The interpretation of the results shows that when there is a PAR score of more than 70% represents a very high standard of treatment, anything less than 50% shows an overall poor standard of treatment and below 30% means that the patients malocclusion has not been improved by orthodontic treatment

The results should only be compared using a group of patients rather than individual bases as this could show completely different results which wouldn't be representative of the standard of treatment being carried out

Index of Orthodontic Treatment Need (IOTN)

This index was discovered and tested in 1989 by Brook and Shaw in England.

IOTN is the most widely used index for measuring the incidence of orthodontic treatment need, however, it does not specify the stage at which treatment should be carried out. This index is used for full dentition but also used for children with mixed dentition.

The Scottish government advised NHS boards and practitioner services in October 2011 of the introduction of the IOTN as a means of assessing orthodontic treatment.

This index easily identifies the individuals who can really benefit from orthodontic treatment by assigning them a treatment priority.

The IOTN scale including the dental health component (DHC) and an aesthetic component (AC). The aesthetic component used a scale of 10 colour photographs showing different levels of dental attractiveness. The pictures are then compared to the patient's teeth by the orthodontist who will score accordingly.

The IOTN is used in the following manner:

Memorandum of Orthodontic Screen and Indication for Orthodontic Treatment

This index was implemented in 1990 by Danish national board of health.

In 1990 a Danish system was introduced based on health risks related to malocclusion, where it describes possible damages and problems arising from untreated malocclusion which allows for the identification of treatment need. 

This mandate introduced a descriptive index that is more valid from a biological view, using qualitative analysis instead of a quantitative.

Ideal Tooth Relationship Index

The ITRI was established in 1992 by Haeger which utilises both intra-arch and inter-arch relationships to generate index scores to compare the entire dentitions occlusion. This index is of use as it divides the arches into segments which would result in a more accurate outcome.

This index evaluates tooth relationships from a morphological perspective which has been of use when evaluating the results of orthodontic treatment, post-treatment stability, settling, relapse and different orthodontic treatment modalities.

The ITRI can allow for comparisons to be made in an objective and quantitative manner that allows for statistical analysis of orthodontic outcomes.

Need for Orthodontic Treatment Index (NOTI)

This index was first described and implemented in 1992 by Espeland LV et al and is also known as the Norwegian Orthodontic Treatment Index.

This index is used by the Norwegian health insurance system and due to this it is designed for allocation of public subsidies of treatment expenses, and the amount of reimbursement which is related to the category of treatment need. It classifies malocclusions into four categories based on the necessity of the treatment need.

Risk of Malocclusion Assessment (ROMA)

This is a tool used to assess treatment need in young patients by evaluating malocclusion problems in growing children, assuming that some aspects may change under positive or negative effects of craniofacial development. It was published for use in 1998 by Russo et al. 

This index illustrates the need for orthodontic intervention and is used to establish a relationship between the registered onset of orthodontic treatment and disorders inhibiting growth of facial and alveolar bones, and the development of the dentition along with the IOTN index.

This index can be used in exchange for the IOTN scale as it is quick and easy to apply as a screening test to decide whether and when to refer patients to specialist orthodontists. 

Index of Complexity, Outcome and Need (ICON)

This index was produced in 2000 by Charles Daniels and Stephen Richmond in Cardiff and has been investigated to illustrate that it can be used to replace the PAR and IOTN scale as a means of determining need and outcome of orthodontic treatment.

This index measures the following to produce a scoring system:

• Dental aesthetics as measured by the aesthetic component of the IOTN
• The presence of a cross bite
• Anterior vertical relationship as measured by PAR
• Upper arch crowding/spacing on a 5 point scale
• Buccal segment Antero-posterior relationship as measured by PAR.

The measurements are added together to produce a score which can be interpreted by score ranges that give need for treatment, complexity and degree of improvement. 

This system claims to be more efficient than the PAR and IOTN indices as it only requires a single measurement protocol but this has still to be validated to be used in the UK and the issue that It does not suitably predict appearance, function, speech or treatment need for individuals attending general dental practice for routine dental treatment, so for these reasons is it generally never used.

Baby-ROMA

This was established in 2014 by Grippaudo et al for use in assessing the risks/benefits of early orthodontic therapies in the primary dentition.

It is a paediatric type version of the ROMA scale. It measures occlusal parameters, skeletal and functional factors that may represent negative risks for a physiological development of the orofacial region, and indicates the need for preventative or interceptions orthodontic treatment using a score scale.

This index was designed as it has been observed that some of the malocclusion signs observed in the primary dentition can deteriorate with growth while others remain the same over time and others can even improve. This index is therefore used to classify the malocclusions observed at an early stage on a risk based scale.

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Training

There are several specialty areas in dentistry, but the specialty of orthodontics was the first to be recognized within dentistry. Specifically, the American Dental Association recognized orthodontics as a specialty in the 1950s. Each country has their own system for training and registering orthodontic specialists.

Canada

In Canada, obtaining a dental degree, such as a Doctor of Dental Surgery (DDS) or Doctor of Medical Dentistry (DMD), would be required before being accepted by a school for orthodontic training. Currently, there are 10 schools in the country offering the orthodontic specialty. Candidates should contact the individual school directly to obtain the most recent pre-requisites before entry. The Canadian Dental Association expects orthodontists to complete at least two years of post-doctoral, specialty training in orthodontics in an accredited program, after graduating from their dental degree.

United States

Similar to Canada, there are several colleges and universities in the United States that offer orthodontic programs. Every school has a different enrollment process, but every applicant is required to have graduated with a DDS or DMD from an accredited dental school. Entrance into an accredited orthodontics program is extremely competitive, and begins by passing a national or state licensing exam.

The program generally lasts for two to three years, and by the final year, graduates are to complete the written American Board of Orthodontics (ABO) exam. This exam is also broken down into two components: a written exam and a clinical exam. The written exam is a comprehensive exam that tests for the applicant's knowledge of basic sciences and clinical concepts. The clinical exam, however, consists of a Board Case Oral Examination (BCOE), a Case Report Examination (CRE), and a Case Report Oral Examination (CROE). Once certified, certification must then be renewed every ten years. Orthodontic programs can award the Master of Science degree, Doctor of Science degree, or Doctor of Philosophy degree depending on the school and individual research requirements.

Bangladesh

Dhaka Dental College in Bangladesh is one of the many schools recognized by the Bangladesh Medical and Dental Council (BM&DC) that offer post-graduation orthodontic courses. Before applying to any post-graduation training courses, an applicant must have completed the Bachelor of Dental Surgery (BDS) examination from any dental college. After application, the applicant must take an admissions test held by the specific college. When successful, selected candidates undergo training for six months.

United Kingdom

Throughout the United Kingdom, there are several Orthodontic Specialty Training Registrar posts available. The program is full-time for three years, and upon completion, trainees graduate with a degree at the Masters or Doctorate level. Training may take place within hospital departments that are linked to recognized dental schools. Obtaining a Certificate of Completion of Specialty Training (CCST) allows an orthodontic specialist to be registered under the General Dental Council (GDC). An orthodontic specialist can provide care within a primary care setting, but to work at a hospital as an orthodontic consultant, higher level training is further required as a post-CCST trainee. To work within a university setting, as an academic consultant, completing research toward obtaining a PhD is also required.

Pakistan

In Pakistan to be enrolled as a student or resident in postgraduation orthodontic course approved by Pakistan medical and dental council, the dentist must graduate with a Bachelor of Dental Surgery (BDS) or equivalent degree. Pakistan Medical & Dental Council (PMDC) has a recognized program in orthodontics as Master in Dental Surgery (MDS) orthodontics and FCPS orthodontics as 4 years post graduation degree programs, latter of which is conducted by CPSP Pakistan.

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Oral home care techniques

The presence of orthodontic appliances placed on the teeth makes traditional oral home care techniques very challenging to perform. With orthodontic appliance placement, comes a potential increase in plaque accumulation and cariogenic bacteria levels in the mouth. This makes effective cleaning that much more crucial to maintain good oral health.

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See also

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References

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External links

• What is a Board Certified Orthodontist?

Source of the article : Wikipedia