Orthodontists' use of remote monitoring platforms pre-, amid, and post-COVID-19: a survey study.

BACKGROUND: Did the COVID-19 pandemic affect orthodontists' use of remote monitoring platforms? The goal of this research was to examine orthodontists' experiences implementing remote monitoring platforms before, during, and after the initial COVID-19 lockdown. METHODS: In this descriptive cross-sectional survey study, an electronic, anonymous questionnaire consisting of a series of 31 short-answer and multiple-choice questions was administered to an international sampling of practicing orthodontists. The target population in the study included currently practicing orthodontists who were graduates of an accredited orthodontic residency program. Participants were recruited in 2021 through collaboration with the American Association of Orthodontists (AAO) Partners in Research Program and the Harvard School of Dental Medicine Orthodontic Alumni Association. Descriptive analysis was conducted, reporting frequency (N and %) distributions for each question. The questionnaire aimed to describe whether orthodontists incorporated remote monitoring platforms into their practices, their experiences doing so, and if the COVID-19 pandemic influenced their use of these resources. RESULTS: Orthodontists' use of remote monitoring platforms was negligible prior to the pandemic; however, a quarter of surveyed orthodontists began using a remote monitoring platform during COVID-19 and nearly all respondents plan to continue using remote monitoring for the foreseeable future. Approximately half of orthodontists believe most patients' treatment progress can be monitored to the standard of care between in-person orthodontic appointments using remote monitoring platforms. Half of the orthodontists who do not currently use a remote monitoring platform in their practice are interested in learning more about how to implement one. CONCLUSIONS: The COVID-19 pandemic led to an increase in the interest and adoption of remote monitoring platforms in orthodontic practices. Most orthodontists had not incorporated remote monitoring platforms into their practices prior to the COVID-19 pandemic. However, this study revealed that a subset of orthodontists utilized the pandemic as motivation to incorporate remote monitoring into their practices and an additional group of orthodontists were interested in incorporating one in the future. Remote monitoring platforms garnered interest and importance with the arrival of the COVID-19 pandemic and may only have an increasing role in the field in years to come.

Invisalign Lite: a cross-sectional investigation of orthodontist treatment-planning practices.

OBJECTIVES: To survey treatment-planning practices of orthodontists related to the Invisalign Lite clear aligner appliance (Align Technology, San Jose, Calif). MATERIALS AND METHODS: Patients satisfying inclusion and exclusion criteria and treated with Invisalign Lite were selected from a database containing more than 17,000 patients. Relevant data regarding treatment-planning practices were obtained from Align Technology's treatment-planning facility, ClinCheck, and evaluated. RESULTS: Most (n = 135; 79.9%) patients were female and had a median (interquartile range [IQR]) age of 30.5 (23.8, 43.1) years. The median (IQR) number of aligners for the sample was 23.0 (14, 28) for the maxilla and 24 (14, 28) for the mandible. Most (n = 122; 72.2%) patients required at least one additional series of aligners. More locations for interproximal reduction (IPR) were prescribed in the mandible (mean 1.91 [1.78]) than in the maxilla (1.03 [1.78]; P < .024) in the initial accepted plan of all patients. More teeth were prescribed composite resin (CR) attachments in the maxilla (P < .0001) in the initial accepted plan of all patients. Issues regarding tooth position protocols (n = 50; 53.3%) and requirement for additional IPR (n = 68; 45.3%) were reasons for treatment plan changes before acceptance of the initial treatment plan by orthodontists. CONCLUSIONS: More than 7 of 10 patients required at least one additional series of aligners after the initial series of Invisalign Lite aligners was completed. Prescription of IPR was more common in the mandible, and prescription of CR attachments was more common in the maxilla.

Performance of dental students, orthodontic residents, and orthodontists for classification of midpalatal suture maturation stages on cone-beam computed tomography scans - a preliminary study.

BACKGROUND: Assessment of midpalatal suture maturation on cone-beam computed tomography (CBCT) scans is performed by visual inspection and is therefore subjective. The extent to which the assessment of midpalatal suture maturation is affected by rater experience has not been adequately explored in the existing literature, thus limiting the availability of evidence-based findings. This study compared the outcomes of classification by dental students, orthodontic residents, and orthodontists. METHODS: Three different groups of students, orthodontic residents, and orthodontists evaluated 10 randomly chosen CBCT scans regarding midpalatal suture maturation from a pool of 179 patients (98 female and 81 male patients) aged 8 - 40 years which were previously classified by evaluating CBCT scans. The pool was set as benchmark utilizing midpalatal suture maturation classification by one examiner (OsiriX Lite version 11.0; Pixmeo SARL, Bernex, Switzerland). For assessment of intra-rater reliability of the examiners of each group the randomly chosen subjects were reclassified for midpalatal suture maturation after a wash-out period of two weeks by using the same software. Statistical analysis was performed to evaluate intra- and interrater reliability of the three groups with differing experience level. RESULTS: Groupwise intra-rater reliability assessment between the classification and reclassification was weak for examiners with a low level of experience (k = 0.59). Orthodontists had highest degree of agreement with regard to benchmark classification with an inter-rater reliability to be considered as moderate (k = 0.68). CONCLUSIONS: Assessment of midpalatal suture maturation on CBCT scans appears to be a subjective process and is considerably related to the experience level of the examiner. A high level of clinical experience seems to be favorable but does not necessarily ensure accurate results.

Quality assessment of available Internet information on early orthodontic treatment.

BACKGROUND: This study aimed to evaluate the content, reliability, quality and readability of information on Internet websites about early orthodontic treatment. METHODS: The "early orthodontic treatment" search term was individually entered into four web search engines. The content quality and reliability were reviewed with DISCERN, Journal of American Medical Association (JAMA), and Health on the Net code (HONcode) tools using the contents of websites meeting predetermined criteria. The readability of websites was evaluated with Flesch Reading Facilitate Score (FRES) and Flesch-Kincaid Grade Level (FKGL). RESULTS: Eighty-six websites were suitable for inclusion and scoring of the 200 websites. 80.2% of websites belonged to orthodontists, 15.1% to multidisciplinary dental clinics and 4.7% to professional organizations. The mean DISCERN score of all websites (parts 1 and 2) was 27.98/75, ranging between 19 and 67. Professional organization websites had the highest scores for DISCERN criteria. Moreover, 45.3% of websites were compatible with JAMA's disclosure criterion, 7% with the currency criterion, 5.8% with the authorship criterion and 5.8% with the attribution criterion. Only three websites met all JAMA criteria, and these websites belonged to professional organizations. None of the websites had the HONcode logo. Mean FRES and FKGL were 47.6 and 11.6, respectively. CONCLUSIONS: The quality of web-based information about early orthodontic treatment is poor, and readability is insufficient. More accurate and higher quality Internet sources are required on the web.

Attractive combinations of female gingival displays, buccal corridor sizes, and facial heights according to orthodontists, dentists, and laypeople of different ages and sexes: a psychometric study.

INTRODUCTION: Esthetics plays a crucial role in orthodontics and many other dental and medical fields. To date, no study has assessed the combined effects of the 3 facial features 'facial height, gingival display (GD), and buccal corridor size (BC)' on facial/smile beauty. Therefore, this study was conducted for the first time. METHODS: In this psychometric diagnostic study, beauty of 27 randomized perceptometric images of a female model with variations in facial heights (short, normal, long), gingival displays (0, 2, 4, 6 mm), and buccal corridor sizes (2%, 10%, 15%, 20%, 25%) were evaluated by 108 judges (36 orthodontists, 36 dentists, 36 laypeople) using a 5-scale Likert scale (1 to 5). Combined effects of facial heights, GDs, BCs, judges' sexes, ages, and jobs, and their 2-way interactions were tested using a mixed-model multiple linear regression and a Bonferroni test. Zones of ideal features were determined for all judges and also for each group using repeated-measures ANOVAs and the Bonferroni test (α=0.05). RESULTS: Judges' sex but not their age or expertise might affect their perception of female beauty: men gave higher scores. The normal face was perceived as more beautiful than the long face (the short face being the least attractive). Zero GD was the most attractive followed by 4 mm; 6 mm was the least appealing. BCs of 15% followed by 10% were the most attractive ones, while 25% BC was the worst. The zone of ideal anatomy was: long face + 0mm GD + 15% BC; normal face + 2mm GD + 15% BC; long face + 2mm GD + 15% BC; normal face + 0mm GD + 15% BC. CONCLUSIONS: Normal faces, zero GDs, and 15% BCs may be the most appealing. Facial heights affect the perception of beauty towards GDs but not BCs.

Treatment choice for first permanent molars affected with molar-incisor hypomineralization, in patients 7-8 years of age: a questionnaire study among Swedish general dentists, orthodontists, and pediatric dentists.

PURPOSE: The aim of this study was to investigate attitudes and preferred therapy choice for first permanent molars (FPM) with Molar-Incisor Hypomineralization (MIH). METHODS: An online questionnaire was sent out to general dentists (n = 559) working in the Public Dental Service in Region Västra Götaland, orthodontists (n = 293), and pediatric dentists (n = 156) (members from each interest association), in Sweden. The questionnaire contained three parts: general questions regarding the respondents, patient cases, and general questions regarding extraction of FPMs with MIH. Statistics were carried out using Chi-squared tests, with a significance level of 5%. RESULTS: A response rate of 36% was obtained. Orthodontists and pediatric dentists were more prone to extract FPMs with both moderate and severe MIH, compared to general dentists. When restoring FPMs with moderate MIH, resin composite was preferred. Compared to the general dentists, the pediatric dentists were more prone to choose glass-ionomer cement in the FPMs with severe MIH. The most common treatment choice for FPMs with mild MIH was fluoride varnish. "When root furcation is under development of the second permanent molar on radiographs" was chosen as the optimal time for extracting FPMs with severe MIH, and the general dentists based their treatment decisions on recommendations from a pediatric dentist. CONCLUSION: Extraction of FPMs with moderate and severe MIH is considered a therapy of choice among general dentists and specialists, and the preferred time of extraction is before the eruption of the second permanent molar.

Civil liability of orthodontists and aligner manufacturers in the treatment with orthodontic aligners.

INTRODUCTION: The use of clear aligners as an alternative to fixed orthodontic appliances has become popular due to the aesthetic demands of adult patients seeking orthodontic treatment. However, orthodontists' lack of knowledge about the legal consequences of their activities, and the lack of solid scientific evidence raise concerns regarding civil liability in this type of treatment. Marketing campaigns of manufacturing companies often exaggerate promises of results, and ignore the lack of scientific evidence. Patients, as consumers, are protected by the Consumer Protection Code, whereas orthodontists are considered treatment providers. Therefore, they can be held liable for damage caused to patients, whether by subjective or objective fault. OBJECTIVE: This article aims to identify the civil responsibilities of orthodontists and aligner manufacturing companies, by means of a literature review, providing basic legal guidance to help professionals protect themselves from possible lawsuits related to treatment with orthodontic aligners. CONCLUSIONS: The study highlights the importance of knowledge of legal notions in treatments with orthodontic aligners by orthodontists, who should legally safeguard themselves through individual written contracts, avoiding obligation of results. In addition, in cases of legal claims, it is possible that the manufacturing companies are jointly and severally liable for possible damages claimed by the patient.

Awareness about the orthodontic specialty: A survey study.

BACKGROUND: This study aimed to examine how well patients can differentiate between orthodontists and dentists. METHODS: Four hundred patients who applied to the Ondokuz Mayis University Faculty of Dentistry, Department of Oral and Maxillofacial Radiology between March and November of 2022 were queried regarding the difference between an orthodontist and a dentist via a face-to-face survey. The respondents were separated into the following two study groups: patients who had previously undergone orthodontic treatment and those who had not. Demographic data of the patients, such as age, sex, educational status, and monthly income, were also collected, and the effects of these factors on their doctor preferences were analyzed. RESULTS: The vast majority of respondents (>85%) thought that a dentist should be an orthodontic specialist to provide orthodontic treatment. Seven percent of patients chose to receive orthodontic treatment from a dentist. Patients who chose an orthodontist for their treatment were predominantly female and had a high income and a higher level of education. Patients who had a history of orthodontic treatment were better aware of the profession of orthodontics than those who did not. CONCLUSIONS: The results indicated that the respondents did not fully understand the clear distinction between an orthodontist and a dentist. This outcome suggests that education concerning this issue is required.

2023-2024 American Board of Orthodontics practice analysis study: Part 1.

As a specialty board, the American Board of Orthodontics (ABO) serves to protect the public and the orthodontic specialty by certifying orthodontists. The demonstration of commitment to lifelong learning and self-improvement is critical to achieving the highest level of patient care. The ABO completed a practice analysis study in 2023 to ensure all examinations represent current assessments of proficiency in orthodontics at a level of quality that satisfies professional expectations. The practice analysis is essential to providing a demonstrable relationship between the examination content and orthodontic practice and provides a critical foundation for ABO's examination programs.

Evaluation of the impact of orthodontists' smile with malocclusions on social media and professional credibility.

OBJECTIVES: This study assessed laypeople's perceptions of orthodontist credibility based on malocclusions and whether these views affect their choice to seek treatment. Eye-tracking technology and questionnaires were utilized. MATERIALS AND METHODS: Ninety-five lay raters, through eye tracking and a questionnaire, assessed 12 images of orthodontists with malocclusions. Malocclusions were categorized by the Index Of Treatment Need (IOTN) as grade 1 (near ideal), 3 (anterior crowding), and 5 (with diastemas). Fixation points were recorded, and credibility was gauged via questionnaires. A Mentimeter word cloud was generated. RESULTS: IOTN 1 orthodontists were viewed as more credible than IOTN 3 (p < 0.001) and 5 (p < 0.001). Raters were more willing to receive treatment from IOTN 1 orthodontists. The focus for IOTN 1 was between eyes and mouth, while IOTN 3 and 5 were on the mouth. "Crooked teeth" and "spacing" were predominant in word clouds for IOTN 3 and 5. CONCLUSION: Orthodontists with an IOTN grade 1 rating were perceived as more competent, reliable, and professional, thus making it more likely for laypeople to choose them as their preferred providers. CLINICAL RELEVANCE: The smiles of professionals play a significant role in laypeople's decision to choose them as their orthodontist, and strategic utilization of social media can effectively deliver health information to a larger audience in a faster and more direct manner.

Enhancing skeletal stability and Class III correction through active orthodontist engagement in virtual surgical planning: A voxel-based 3-dimensional analysis.

INTRODUCTION: Skeletal stability after bimaxillary surgical correction of Class III malocclusion was investigated through a qualitative and quantitative analysis of the maxilla and the distal and proximal mandibular segments using a 3-dimensional voxel-based superimposition among virtual surgical predictions performed by the orthodontist in close communication with the maxillofacial surgeon and 12-18 months postoperative outcomes. METHODS: A comprehensive secondary data analysis was conducted on deidentified preoperative (1 month before surgery [T1]) and 12-18 months postoperative (midterm [T2]) cone-beam computed tomography scans, along with virtual surgical planning (VSP) data obtained by Dolphin Imaging software. The sample for the study consisted of 17 patients (mean age, 24.8 ± 3.5 years). Using 3D Slicer software, automated tools based on deep-learning approaches were used for cone-beam computed tomography orientation, registration, bone segmentation, and landmark identification. Colormaps were generated for qualitative analysis, whereas linear and angular differences between the planned (T1-VSP) and observed (T1-T2) outcomes were calculated for quantitative assessments. Statistical analysis was conducted with a significance level of α = 0.05. RESULTS: The midterm surgical outcomes revealed a slight but significantly less maxillary advancement compared with the planned position (mean difference, 1.84 ± 1.50 mm; P = 0.004). The repositioning of the mandibular distal segment was stable, with insignificant differences in linear (T1-VSP, 1.01 ± 3.66 mm; T1-T2, 0.32 ± 4.17 mm) and angular (T1-VSP, 1.53° ± 1.60°; T1-T2, 1.54° ± 1.50°) displacements (P >0.05). The proximal segments exhibited lateral displacement within 1.5° for both the mandibular right and left ramus at T1-VSP and T1-T2 (P >0.05). CONCLUSIONS: The analysis of fully digital planned and surgically repositioned maxilla and mandible revealed excellent precision. In the midterm surgical outcomes of maxillary advancement, a minor deviation from the planned anterior movement was observed.

A review of oral pathology in orthodontics. Part 1: Soft-tissue pathology.

Orthodontists are well placed to detect soft-tissue disease of the oral cavity and associated structures because of the frequent repeat examinations of their patients. This review describes the clinical manifestations, pathologic features, and treatment of the soft-tissue pathology most likely to be encountered by the orthodontist and uncommon soft-tissue disease with significant implications for the patient. The recognition of soft-tissue disease will allow reassurance, referral, and early intervention when required.

Does clinical experience affect the bracket bonding accuracy of guided bonding devices in vitro?

OBJECTIVES: To study whether and how the clinical experience of the operator affects the accuracy of bracket placement using guided bonding devices (GBDs) in vitro. MATERIALS AND METHODS: Five resin models were bonded virtually with brackets, and the corresponding GBDs were generated and three-dimensionally printed. Nine operators, which included three dental students, three orthodontic students, and three orthodontists, bonded the brackets on the resin models using GBDs on a dental mannequin. After being bonded with brackets, the models were scanned, and the actual and designed positions of the brackets were compared. RESULTS: There was no immediate debonding. The orthodontists spent a significantly shorter time (22.36 minutes) in bracket bonding than the dental students (24.62 minutes; P < .05). The brackets tended to deviate to the buccal side in the dental student group. Linear deviations tended to be smallest in the orthodontic student group, but no significant difference was found among operators with different clinical experience (P > .5). All linear and angular deviations in each group were under 0.5 mm and 2°, respectively. CONCLUSIONS: Clinical experience was positively related to the bonding accuracy using GBDs, especially in the buccolingual dimension. Inexperience also led to longer bonding duration. However, bonding accuracy was clinically acceptable in general.

Association between crowding estimation and extraction recommendations in orthodontics.

INTRODUCTION: Little is known about how precisely orthodontists in the United States (US) assess crowding or at what range of crowding they recommend extraction. This study aimed to assess the relationship between estimated crowding in patients with a Class I relationship and extraction recommendation by orthodontists in the US. The secondary aims were to evaluate the accuracy and precision of clinician estimations and determine if clinician background traits play a role in extraction decision-making. METHODS: An electronic survey was prepared using 4 patients with a Class I relationship with anterior crowding selected from a University Orthodontics Clinic and was sent to approximately 10,400 subjects through Facebook and the American Association of Orthodontists Partners in Research program. RESULTS: From the 297 responses received, most clinicians recommended extraction once crowding reached 9-10 mm in either the maxilla or the mandible. The data from 2 patients suggest this decision was more strongly correlated with mandibular crowding. Clinician estimations varied widely but, on average, were precise within approximately 2 mm of objective measurements. There was a tendency to overestimate crowding, especially by Northeastern practitioners. Clinicians who reported routinely measuring crowding or who reported that they recommended extractions to >10% of their patients were 1.2-2.0 and 1.4-1.6 times more likely, respectively, to recommend extraction in the patients. CONCLUSIONS: Crowding estimation was highly subjective and varied widely among clinicians. Most clinicians recommended extraction once maxillary or mandibular crowding approximated 9-10 mm. Some clinician demographics were correlated with the precision and accuracy of estimations and the likelihood of extraction in the patients.

Oral maxillofacial surgeons and Orthodontists' perceptions about anterior inferior crowding and indications of mandibular third molar extraction.

BACKGROUND: There are still many doubts about anterior inferior crowding and indications of mandibular third molar extraction, although it is very studied subject in the literature. The aim of this study was to evaluate the perceptions of oral maxillofacial surgeons (OMFSs) and orthodontists about anterior inferior crowding and indications of mandibular third molar extraction. MATERIAL AND METHODS: A web-based survey was developed and sent to professionals in order to collect their opinion about the fact that third lower molars cause crowding and questions about the indication of third molars for orthodontic treatment. Descriptive analysis was performed and Chi-square or G tests were applied with a 95% confidence interval. RESULTS: The study included a total of 218 participants, of whom 115 were OMFSs and 103 were orthodontists. The results showed that 56.5% of OMFSs and 35.0% of orthodontists believe that the lower third molars cause anterior inferior crowding (p<0.001). A total of 91.3% of OMFSs and 70.9% of orthodontists indicate the extraction of lower third molars to aid orthodontic treatment (p<0.001). CONCLUSIONS: It can be concluded that in being an oral maxillofacial surgeon, a higher odds ratio is observed to consider that lower third molars cause dental crowding compared to those who are orthodontist. The indication of exodontia of lower third molars for orthodontic treatment was more frequent among OMFSs when compared to orthodontists.

Gender disparity of invited speakers at the American Association of Orthodontists Annual Session: A cross-sectional analysis 2015-2023.

INTRODUCTION: The American Association of Orthodontists (AAO) Annual Session aims to educate members using expert speakers in the field. Selection to speak is an honor and can help further an orthodontist's career and credibility. A European study found a significant gender discrepancy in selected speakers at their orthodontic meeting. This has not been investigated in the United States. METHODS: Speaker names from the 2015-2023 AAO Annual Sessions were obtained and analyzed for gender and then compared with active membership and orthodontic faculty percentages. In addition, the gender of each General Chair and Doctors' Program Chair was analyzed and then compared with the female speaker and membership percentages. Because AAO research award winners are selected blindly, show expertise in the field, and are provided an opportunity to speak at the Annual Session, their gender was also confirmed and compared with membership percentage and female speaker percentage. Two-way chi-square tests were used, and P values of <0.05 were considered statistically significant. Mann-Kendall trend tests analyzed any potential changes in gender representation among AAO active memberships and AAO Annual Session speakers. RESULTS: Female doctors were underrepresented as speakers (P values ranged from <0.001 to <0.05) in every year studied except 2020 compared with active membership and female faculty percentages. Female doctors were also significantly underrepresented as Annual Session General Chairs and Doctors' Program Chairs (P <0.01). The difference in female doctor representation among research awards winners (63%) compared with the Annual Session speakers (19%) was highly significant. Female representation in AAO active membership shows a significant increase from 2015 to 2023. The ratio of female-to-male speakers appears to be increasing but did not reach statistical significance. CONCLUSIONS: Female doctors are underrepresented as selected speakers at the AAO Annual Session but comprise the majority of research award recipients. Efforts to provide opportunities for women to showcase their knowledge should be implemented.

Why orthodontists need to know about molar incisor hypomineralization.

Molar incisor hypomineralization (MIH) is a systemic developmental qualitative defect of the enamel that affects 1-4 first permanent molars with or without incisor involvement. Enamel hypomineralization is identified visually as a demarcated opacity with a clear border with varying extensions and can be white, yellow, or brown. This opacity is characterized by a reduced quality of enamel that is of normal thickness but not fully mineralized. It is very common for the affected teeth to present with posteruptive breakdown, making them susceptible to caries, leading to their subsequent loss. Thus, MIH is a significant dental problem with clinical, economic, and psychosocial implications. The planned extraction of compromised teeth is a valid alternative to complex restorative treatment. Orthodontists' involvement is essential in developing effective treatment strategies for children affected by MIH, contributing to their oral health and well-being.

Assessing inter- and intra-examiner reliability of orthodontists in devising incisor position objectives on cephalograms: a comparative study between senior and junior practitioners.

BACKGROUND: Effective orthodontic treatment planning hinges on accurately defining incisor position objectives (IPO) in cephalograms. The purpose of this study was to estimate the inter-examiner and intra-examiner reliability of different orthodontists in devising IPOs on cephalograms. METHODS: Ten orthodontists, who were divided into to the senior group (N = 5) and the junior group (N = 5) based on their clinical experience, formulated IPOs for 60 pre-treatment cephalograms twice with an interval of 2 weeks, utilizing SmartOrtho software. The type and magnitude of movement were read directly in the software. A paired t-test assessed the absolute differences between the first and second IPO devising within each group and between the senior and junior groups in each time's IPO devising. The intra-examiner and inter-examiner reliabilities were calculated. RESULTS: There were significant differences in all types of upper incisor movement and lower incisor protrusion/retraction movement between the first and second IPO devising of the senior group. The junior group exhibited significant differences in the twice the upper incisor extrusion/intrusion movement and upper incisor torque movement devising. Additionally, significant differences in all types of incisor movement between the senior and junior groups in each time's IPO devising. Intra-examiner reliabilities were excellent for both two groups and moderate for the junior group in most types of incisor movement, respectively. The inter-examiner reliability between the two groups ranged from moderate to good across different types of incisor movement. CONCLUSIONS: Among orthodontists, both senior and junior practitioners displayed the best inter-examiner reliability in lower incisor extrusion/intrusion movement. In terms of intra-examiner reliability, senior orthodontists had better intra-examiner reliability in upper incisor position objectives devising than the junior orthodontists. Furthermore, senior orthodontists tended to adopt a more recessive, intrusive, and lingually torqued incisor position approach compared to junior orthodontists.