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Standardized orthodontic record is a fundamental initial step in orthodontic practice that aid in accurate diagnosis and problem list formulation to get the proper treatment plan.
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International Journal of Medical Research &
Health Sciences, 2018, 7(12):
169
ISSN No: 2319-5886
Evaluation of the Quality of Orthodontic Records in Comparison with
the International Guidelines
Dhiaa J. Aldabagh, Dheaa H. Al-Groosh, Akram Faisal Alhuwaizi and Harraa S.
Mohammed-Salih*
Department of Orthodontics, College of Dentistry, University of Baghdad, Iraq
*Corresponding e-mail: dr.harraas.ms@gmail.com
ABSTRACT
Background: Standardized orthodontic record is a fundamental initial step in orthodontic practice that aid in
accurate diagnosis and problem list formulation to get the proper treatment plan. Aim of the study: To assess the
accuracy of pre-treatment orthodontic records as appose to a specic proposed standardized criterion. Material
and Methods: A set of 78 patient records were recruited from a total sample size of 120 patients that fullled the
selection criteria. A set of study model with the dental radiograph (panoramic and lateral cephalometric) as well
as patient photographs were evaluated with certain criteria which were approved by the European and American
Board of Orthodontists (EBO), (ABO) respectively, and the level of their acceptance was analyzed by estimating the
percentage value of each criterion. Results: Evaluating results of both study model and intraoral photograph (lateral
and occlusal views) showed a high level of non-acceptance, while panoramic radiograph and extraoral photograph
(frontal and lateral) and only frontal view of intraoral photograph showed a higher percentage of acceptance. The
lack of a required number of the lateral cephalometric radiograph and the absence of oblique and relaxed smile
views of facial photographs were prohibiting their evaluation. Conclusion: The ndings of this study indicate that
more training courses may be needed for study model fabrication and intraoral photography by providing more
facilities that aid in documenting with a total standardization. However, this may not be easily possible, but, it must
be remembered that if it is not documented accurately, it is not valuable.
Keywords: Orthodontic records, EBO, Study model, Photograph
INTRODUCTION
Orthodontic records are a fundamental aid, due to which its value cannot be neglected. Even diagnosis is dependent
on standardized, accurate and reliable orthodontic records. The vital information which is required to diagnose a
malocclusion and development of an orthodontic treatment plan consists of a comprehensive clinical examination
including medical, dental, and social histories, models, photographs, panoramic and/or lateral cephalometric
radiographs [1].
Each particular case requires specic types of records to provide certain diagnostic information to the orthodontist to
aid him/her in diagnosing and determining the best possible treatment plan. It is important to recognize that records
are considered as an adjunct and are not used as a replacement for clinical examination [2,3].
Plaster study model has a long and proven history in orthodontics. They have been the “gold standard” in orthodontics,
with advantages ranging from being a dental procedure routinely conducted, easily produced, inexpensiveness and
simplicity of measurements to plaster casts being able to be mounted on an articulator for study in three-dimensions [4,5].
The panoramic radiograph is the universally used radiograph for orthodontic patients. However, in many patients with
complex dental developmental disturbances and those with skeletal or functional abnormalities, additional radiographs
may be necessary. Panoramic radiographs should be of sufcient quality to permit interpretation for diagnosis [6].
Cephalometric analysis and methods of superimposition are useful in monitoring the changes that are due to growth
or a combination of growth and treatment [7]. Cephalograms are usually not required as adjuncts for orthodontic
diagnosis and treatment in adults, or for cases involving the correction of a minor problem in children. However, if jaw
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Kadhim, et al.
relationships and incisor positions are being changed with treatment, one should denitely consider a cephalogram, an
integral part of the diagnostic records [3].
Nowadays, in addition to the ordinary orthodontic goals in obtaining well aligned dentition and functionally stable
occlusion, smile esthetic with harmonious facial balance emphasis the need for proper clinical photography and
become more obvious and essential for proper treatment planning and follow up, as well as for the purposes of the
research and publication for lecturing and teaching presentations. Also, the need for such valuable records for medico-
legal purposes cannot be neglected [8].
All are crucial in the attainment of an accurate diagnosis, which is a prerequisite for successful orthodontic planning
and treatment. The automatic compilation of all diagnostic ndings helps the clinician create the list of problems
present, from which the treatment plan will be developed. The importance of quality records acquisition needs to be
appreciated. Poor-quality records have often been the basis of litigation. All diagnostic records require evaluation-at
least qualitative if not quantitative assessment [9]. Therefore, the aim of this study is to assess the accuracy of pre-
treatment orthodontic records as appose to specic standardized criteria and to establish a protocol for orthodontic
patient’s records.
PATIENTS AND METHODS
Sample
In this study, a total of 120 patient records set of both genders including study model, dental radiographs (panoramic
(OPG and lateral cephalometric) and photographs (facial and intraoral)) were recruited from the archive of the
patient’s records treated by postgraduate students in Orthodontic department, at the College of Dentistry, University
of Baghdad from the period of 2014 to 2016. For quality assessment, only a sample of 78 records set fullled the
inclusion criteria which included:
Patients age 11 years to 36 years
No fractured teeth
No missing teeth
Patients without open bite or complete deep bite
The presence of all rst molars
No visual problems
No clefts (lip/palate)
An excel sheet was used to categorize each record type with accepted and non-accepted values according to the
specic standardize criteria gathered from European Board of Orthodontists (EBO) with modications. These criteria
are as follow:
Study models: The study model is described in Table 1.
Table 1 Assessment criteria of ideal study model as supposed by EBO
Criteria Description
Correct anatomical details They should show the correct anatomical detail of all the teeth and the surrounding tissues.
Base dimensions The base dimensions should be 13 mm from the buccal vestibule to the base surface anteriorly and
35 mm posteriorly from the gingival margin of the 1st molar region to the base of each cast.
Wax or silicone bites Wax or silicone bites used preferably to aid in registration of occlusal relation.
Judgment of occlusion The occlusion judged by placing the upper and lower cast together with the backside of the base on
the table.
Cast identication By placing a label on the back of the upper and lower casts with: patient’s name, operator’s name
and the stage of treatment (before/at the completion of treatment).*
*with modications from EBO by checking patient’s name, stage of treatment and clinician’s name
Dental radiographs: OPG and lateral cephalometric radiographs were evaluated according to the following criteria
as shown in Table 2.
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Table 2 Assessment criteria of ideal radiographs as supposed by EBO
Panoramic Radiograph
Criteria Description
Condyles visibility and positioning The condyles are positioned about equal distance from the inside edges of the image and 1/3
of the way down from the top edge of the image.
Properly labeled (right/left) The radiograph should indicate right/left facial sides properly.
“U” shaped mandible The mandible is “U” shaped from the ramus on one side to the other side.
Magnication Magnication is equal on both sides of the midline
Occlusal Plane The occlusal plane exhibits a slight curve or “smile line,” upwards.
Teeth distortion The roots of the maxillary and mandibular anterior teeth are readily visible with minimal
distortion
Correct exposure Correct radiation exposure produces an image with good resolution.
Lateral cephalometric radiograph
Criteria Description
Scale of magnication The enlargement can be checked easily by the enlargement scale for linear measurements
during analysis.
Soft tissue prole The soft tissue prole should be sharply visible.
Head position Head is in a natural position with Frankfort Horizontal plane parallel to the oor.
Patient Occlusion The patient has the teeth in habitual occlusion.
Correct exposure Strongly recommend occipital region be visible
Photographs
Facial (extraoral) photographs: The standardized criteria for the frontal, lateral and oblique views are shown in
Table 3.
Table 3 Assessment criteria of ideal extraoral photograph (frontal, lateral, and oblique) views as supposed by EBO
Facial (Extra-oral) photographs
Frontal
Criteria Description
Framing of the shot Entire head and neck displayed with the approximate center of the frame is the tip of the nose.
Head position Natural head position with the patient looking forward into the camera.
Leveling of the eyes Eyes are opened and looking into the camera with the inter-pupillary line horizontal to the frame.
White background Use white background to avoid shadows.
Teeth, jaws, lips posture Teeth and jaws are held in relaxed (rest position) with the lips relaxed and in contact (if possible).
Lateral
Criteria Description
Framing of the shot Entire head and neck displayed with left eyelash slightly visible and the approximate center of
the frame are 1.0 cm anterior to the tragus.
Head position Natural head position with eyes looking forward.
Leveling of the eyes Eyes are opened and xed horizontally at a specic eye-level point or at the reection of their
own pupils in a mirror.
White background Use white background to avoid shadows.
Teeth, jaws, lips posture Teeth and jaws are held in relaxed (rest position) with the lips relaxed and in contact (if possible).
Oblique
Criteria Description
Framing of the shot Entire head and neck displayed.
Head position Natural head position with the patient turned his/her head to 45° prole (3/4 prole) and keeping
the body in the previous prole (i.e: lateral view) position.
Leveling of the eyes The eyes are looking into the camera.
Intra-oral photographs: Frontal, lateral (right/left sides) and occlusal (upper and lower) views are assessed according
to the criteria as shown in Table 4.
Table 4 Assessment criteria of ideal intraoral photograph (frontal, lateral (right and left) and occlusal (upper and lower)
views as supposed by EBO
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Intraoral photograph (in occlusion)
Frontal
Criteria Description
Photo orientation The vertical line should pass through the upper frenal attachment as a guide for facial midline occlusal
plane should be horizontal and bisecting the photograph
Shot eld depth There should be equal display of the posterior dentition and all attached gingiva should be visible
Teeth in occlusion Teeth should be in occlusion
Lateral (Right/Left)
Criteria Description
Photo orientation Occlusal plane should be parallel to the frame
Shot eld depth Anteriorly-should display the entire ipsilateral maxillary central incisor at minimum Posteriorly-include
the entire rst molars at minimum All attached gingiva should be visible
Teeth in occlusion Teeth should be in occlusion
Occlusal views
Upper
Criteria Description
Using dental mirror Dental mirror is mandatory in this view
Photo orientation Mid-palatal raphe centered the photograph and used as a guide for its correct orientation
Shot eld Frame the entire arch with minimal lateral soft tissue displayed at least through the rst molars
Lower
Criteria Description
Using dental mirror Dental mirror is mandatory in this view
Photo orientation The midline centered in the frame with the labial surface of the central incisors parallel to the bottom of
the frame
Shot eld Fill the frame with the entire mandibular arch at least through the rst molar
Tongue rolled back Ideally, the tongue should be rolled back or at least not obstructing the view
To ascertain intraexaminer reliability, 15 of the sample records were re-examined after a period of 2 weeks by the
same examiner. The results were tested using kappa-test with the reliability value of a highly signicant level (p
0.05, kappa=0.857-1.000).
Statistical Analysis
By using descriptive statistic to predict the level of the accuracy of recruited patients’ records, the percentage was
used to evaluate the level of acceptance of the collected data for each criterion within each record. Statistical package
for social sciences (SPSS) version 21 was used.
RESULTS
The results of study model assessment showed a high level of non-acceptance in revealing correct anatomical details
(60%), base dimensions (95%), wax or silicon bites (100%) and judgment of occlusion (91%). Whereas, all the
examined casts were fully identied (100%) (Table 5).
Table 5 Percentage values of acceptance level for study model assessment criteria
Criteria Category N=78 %
Correct anatomical details Accepted 31 39.74%
Non-accepted 47 60.26%
Base dimensions Accepted 4 5.13%
Non-accepted 74 94.87%
Wax or Silicone bites Non-accepted 78 100.00%
Judgment of occlusion Accepted 7 8.97%
Non-accepted 71 91.03%
Cast identication Accepted 78 100.00%
Table 6 shows a high percentage of acceptance for the criterion of assessment of panoramic radiograph regarding
condyles visibility (72%), properly labeled (100%), “U” shaped mandible (69%), magnication (71%) and occlusal
plane (74%). However, teeth distortion and correct exposure show a higher percentage of acceptance than non-
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acceptance level but it is less than other previous criteria (59% and 53% respectively).
Table 6 Percentage values of acceptance level for panoramic radiograph criteria
Criteria Category N=78 %.
Condyle visibility and position Accepted 56 71.79%
Non-accepted 22 28.21%
Properly labeled Accepted 78 100.00%
U Shaped mandible Accepted 54 69.23%
Non-accepted 24 30.77%
Magnication Accepted 55 70.51%
Non-accepted 23 29.49%
Occlusal Plane Accepted 58 74.36%
Non-accepted 20 25.64%
Teeth distortion Accepted 46 58.97%
Non-accepted 32 41.03%
Correct exposure Accepted 41 52.56%
Non-accepted 37 47.44%
The percentage of frontal and lateral views of facial photograph showed a high level of acceptance in achieving a
photograph with accepted framing of the shot, head positioned in NHP, leveling of the eyes and teeth, jaws and lips
posture. On the other hand, in both views, a high percentage of non-acceptance for the examined photographs exhibit
shadows as they lack the presence of white background (63% and 76% respectively) (Figures 1 and 2).
Figure 1 Percentage distribution of acceptance level of the facial photograph in frontal view
Figure 2 Percentage distribution of acceptance level of the facial photograph in lateral view
In Figure 3, the frontal view of intraoral photographs is presented, it was interesting to know that the percentage values
of acceptance indicate more than half of the sample was shot with standardizing criteria. Whereas, the photographs in
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the lateral views (right and left sides) showed a high percentage of non-acceptance due to the lack of standardization
in photo orientation and shot depth eld (Figure 4).
Figure 3 Percentage distribution of acceptance level of the intraoral photograph in frontal view
Figure 4 Percentage distribution of acceptance level of the intraoral photograph in lateral view (A: Right side, B: Left
side)
The results of both occlusal views (upper and lower) of intraoral photographs shows a high percentage of non-
acceptance in revealing an image with standardized criteria of shooting with a dental mirror, photo orientation, shot
eld and tongue rolled back (Figure 5).
Figure 5 Percentage distribution of acceptance level of the intraoral photograph in occlusal view (A: Upper, B: Lower)
DISCUSSION
Every patient who needs orthodontic treatment should have at minimum diagnostic records which include the medical
and dental patient history, clinical ndings, TMJ examination, intraoral and extraoral photographs, dental radiographs
(panoramic and cephalometric analysis) and study models [10]. In addition to their importance in providing an
accurate diagnosis and problem list, from which the treatment plan will be developed, these would help orthodontists
to present their treatment outcomes throughout their population as well as will help who so desired to be judged by
national examinations around the world. Because of all these reasons, the records must be prepared with standardized
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criteria, however, there is no “standard” method that should be followed as a rule in obtaining qualied records,
but it can be generally accepted by opinions of many authorities in this eld that would enable the clinician to get a
maximum benet and information.
In the past, many issues were concerned in monitoring and improving the quality of care. Latterly and certainly over
the past decade or so, self-audit, clinical governance, and peer review have become major issues in all branches
of the health industry. Fundamental to these issues is the assessment of quality by peer review. In orthodontics,
several systems have been developed and adapted for specic purposes. On a population scale, where statistical
procedures are essential, standards and indices were designed and applied to measure quality. In the last decade, the
need, effectiveness, and efciency of orthodontic treatment provided by various groups of care providers became a
popular eld of research [6].
In this study, the inclusion criteria for sample selection were formulated in order not to affect the procedure of
assessment. For study model assessment, no fractured or missing teeth were mandatory during evaluation mainly
in the judgment of occlusion. In OPG evaluation, open bite or complete deep bite patients were excluded from the
study as these affect the evaluation of the occlusal plane in open bite cases and in deep bite patients, the appearance
of double images of the palatal vault with the nasal oor is usually above the apices of maxillary teeth which results
in OPG with distorted anterior teeth [6]. For photograph evaluation, the presence of all rst molars is mandatory as it
was considered as a guide to which the shot depth eld should be reached at a minimum. Also, any patient with the
visual problem was excluded as this was affecting on measuring the leveling of the eye criteria. In the evaluating the
occlusal view of upper arch, the palatal raphe is considered as a guide in photo orientation vertically, therefore, no
clefts (lip/palate) patients’ record was included in the study.
In this study, EBO standardized criteria of the diagnostic records which are proposed by the council of this board to the
specialists in orthodontics who would prefer to present their cases were used with some modications regarding the
assessment of study models, radiographs and photographs. According to EBO, 3 sets of dental casts are mandatory:
before treatment, at the completion of treatment and at the (post) retention periods. In this study, before treatment
records are only evaluated for the proposed standardized criteria and the results showed high percentage of non-
acceptance in all criteria except cast identication, which indicate either more training courses regarding how to
prepare study model with good quality may be needed or may be due to the lack of specic facilities that should be
available in cast preparation such as wax or silicon bites and in preparing the base of the cast.
According to EBO, dental radiographs needed for orthodontic patients usually are OPG and lateral cephalometric
radiographs. Routinely, each orthodontic patient should have panoramic radiograph: before treatment and at the
completion of treatment and if necessary during treatment. In the present study, only the radiographs before treatment
are evaluated for their quality assessment and the results showed that the examined panoramic radiography provides
the dentist with an image of good quality of the whole dentition and adjacent structures. While panoramic radiography
is technique sensitive, carefully following the manufacturing instructions and correct patient positioning should be
applied, otherwise unclear and distorted radiographs with low diagnostic quality can be consistently obtained.
Also, lateral cephalometric radiograph with their analysis is mandatory for orthodontic patient mainly those with
skeletal discrepancy and in monitoring the growth changes of growing patients, but unfortunately one of the limitations
of the present study is that only 5 radiographs were available which could not be used for the assessment of the quality.
The lack of an adequate number of lateral cephalometric may be due to the unavailability of the facilities required for
obtaining cephalometric radiographs or due to the nancial causes.
In addition to the importance of the clinical photographs in the documentation of patient status, they are valuable
in allowing the clinician to study and monitor the hard and soft tissue patterns during different stages of treatment.
Frontal, lateral, and oblique facial color photographs should be taken for each patient in the resting position. Nowadays,
an image in frontal view with a relaxed smile is of greater importance in allowing the orthodontist to study the social
setting of the patient by regarding various values of smile esthetic [8].
According to EBO, these views should be printed with approximate dimensions of (5 × 7) cm with the specic
criteria. The extraoral photographs were considered as the easiest and the ready method, that needed only the proper
positioning of the patient and the clinician and of course the proper setup of the camera itself. Therefore, the results
of the present study evaluating the facial photographs showed a high level of acceptance with the standardized criteria.
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Whereas, the results of intraoral photographs showed high percentage of non-acceptance in lateral (right/left) and
occlusal (upper/lower) views, because these are considered more difcult because, in addition, they require dental
photography mirror, special cheek retractors and if possible, well-trained assistant to get an accurate image that
lls the proposed standardized criteria. Also, the absence of oblique and relaxed smile views of facial photographs
prohibits their evaluation.
CONCLUSION
The orthodontic record is an important part of any orthodontic practice. Documenting with total standardization
may not be always possible. But, it must be remembered that if it isn’t documented accurately, it isn’t valuable. The
ndings of this study indicate that more training courses may be needed for study model fabrication and intraoral
photography steps with providing more facilities that aid in documenting with a total standardization. From this
study, by following these proposed standardized criteria which mainly follow the instructions of EBO and considered
them as a protocol must be followed in the fabrication of each record, their quality would be more accepted and the
clinicians can submit their records to national examinations around the world.
DECLARATIONS
Conict of Interest
The authors declared no potential conicts of interest with respect to the research, authorship, and/or publication of
this article.
REFERENCES
[1] Han, Unae Kim, et al. “Consistency of orthodontic treatment decisions relative to diagnostic records.” American
Journal of Orthodontics and Dentofacial Orthopedics, Vol. 100, No. 3, 1991, pp. 212-19.
[2] Proft, William R., Henry W. Fields, and David M. Sarver. Contemporary orthodontics-e-book. Elsevier Health
Sciences, 2014.
[3] Graber, Lee W., et al. Orthodontics-e-book: current principles and techniques. Elsevier Health Sciences, 2016.
[4] Isaacson, Robert J. “Objective and Reproducible Model Assessment.” The Angle Orthodontist, Vol. 80, No. 3,
2010, pp. 607-08.
[5] Rheude, Brian, et al. “An evaluation of the use of digital study models in orthodontic diagnosis and treatment
planning.” The Angle Orthodontist, Vol. 75, No. 3, 2005, pp. 300-04.
[6] Sandler, P. J., and H. S. Duterloo. “European Board of Orthodontists: a professional challenge.” Journal of
Orthodontics, 2003.
[7] Rubin, Robert M. “Making sense of cephalometrics.” The Angle Orthodontist, Vol. 67, No. 2, 1997, pp. 83-5.
[8] Samawi, S. “A short guide to clinical digital photography in orthodontics.” SDOC, 2008.
[9] Abdelkarim, Ahmad, and Laurance Jerrold. “Risk management strategies in orthodontics. Part 1: Clinical
considerations.” American Journal of Orthodontics and Dentofacial Orthopedics, Vol. 148, No. 2, 2015, pp.
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... The American Orthodontic Association also provides some essential data elements for the orthodontic record in the orthodontic guidelines (25). The British Orthodontic Society states the purpose of determining the minimum orthodontic data set to ensure that all patients have received effective treatment (26). ...
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Background: One of the problems in the oral health is lack of coordination and misalignment of teeth, so orthodontic treatments were performed to treat this issue. This treatment is time consuming and the need to document the processes is strongly felt. Dental information management can improve the quality of dental care and reduce the costs by preventing re-procedures. To manage the orthodontics information, the present study aimed to review a minimum orthodontics data set. Methods: This review study was performed using the guidelines and related articles conducted from 2001 to September 2021 through scientific databases and search engine (PubMed, ProQuest, Wiley, Google Scholar, Scopus and Science Direct) using keywords including (minimum data set, health information management, dental records, orthodontics, orthodontic records, malocclusion, and maxillofacial malformations). Results: According to studies, demographic data, general evaluation, extra and intra oral examination, functional examination, temporomandibular joint condition, cephalometric data, cast analysis, evaluation data and treatment plan, progress note, unit summary, dental history, and type of orthodontic treatment have suggested as minimum orthodontics dataset. Conclusion: Developing minimum dataset as a standard approach for better understanding and comparing the data is necessary in the health information management. The present study proposes a minimum data set for implementation of orthodontic information system in Iran. This system will play an important role in improving the oral health indicators of the community and provide access to an electronic health record.
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The background to the formation of the European Board is given and the necessary procedures for obtaining certification of the European Board of Orthodontists (EBO) are described. An example case report is included to give the reader an indication of the type of detail required for each and every case presented. Recommendations are given for prospective candidates who might consider attempting EBO certification in the future.
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The purpose of the present study was to determine the diagnostic and treatment planning value of digital models when compared with plaster study casts. In addition, the level of orthodontic experience of the examiner was assessed to determine whether this would have an influence on the decision-making process. Thirty randomly selected orthodontic patients from the Department of Orthodontics at the University of Alabama were selected for the study. From the 30 record sets, seven were selected attempting to mirror cases required for presentation to the American Board of Orthodontics. The seven evaluators were divided into two groups on the basis of their level of orthodontic experience. Initially, each evaluator assessed each patient record. Each evaluator was given a standardized questionnaire which recorded the evaluator's diagnosis based on use of the digital study models (T1). Regardless of whether the evaluator requested a review of the plaster study casts, the evaluator was given the plaster study casts. The evaluator then, using the plaster casts, filled out another identical questionnaire (T2). A chi-square test was used to determine any group differences in the frequency of changed diagnostic characteristics, treatment mechanical procedures, or proposed treatment plans after evaluating plaster study models. The statistical significance selected was P = .05 level of significance. The results showed that 12.8% of diagnostic characteristics, 12% of treatment mechanic procedures, and 6% of proposed treatment plans changed after T2. The results of the present study indicate that in the vast majority of situations digital models can be successfully used for orthodontic records.
Consistency of orthodontic treatment decisions relative to diagnostic records
  • Unae Han
  • Kim
Han, Unae Kim, et al. "Consistency of orthodontic treatment decisions relative to diagnostic records." American Journal of Orthodontics and Dentofacial Orthopedics, Vol. 100, No. 3, 1991, pp. 212-19.
Orthodontics-e-book: current principles and techniques
  • Lee W Graber
Graber, Lee W., et al. Orthodontics-e-book: current principles and techniques. Elsevier Health Sciences, 2016.
A short guide to clinical digital photography in orthodontics
  • S Samawi
Samawi, S. "A short guide to clinical digital photography in orthodontics." SDOC, 2008.