The clinical training of orthodontic residents encompasses all aspects of current orthodontic practice, including full treatment cases with bands and brackets, early treatment, adult treatment, craniofacial anomalies, orthognathic surgery and TMJ/occlusion. The length of the orthodontic program is 30 months. Given this time frame, the clinical teaching of orthodontics will be divided according to the importance of the above topics to the private practice of orthodontics. In a program of 30 months it is not possible to produce a seasoned and skilled orthodontist, therefore, our program strives to produce a competent beginner. Accordingly, the clinical load of patients is chosen to match the teaching goals of the department.
There is an option to extend the program to 36 months to satisfy European specialty training standards (ERASMUS).
The majority of the cases are treated in the fixed appliance or core clinic. The orthodontic resident spends a full 30 months treating patients within this clinic. During the first year of the program, each resident starts 50 new patients to be treated on 8 half days. The breakdown of the 50 patients is as follows: 10 patients are treated following the Tweed philosophy of treatment, ten following an Edgewise Sliding-Mechanics concept, 25 using a pre-torqued pre-adjusted appliance system, and 5 following the Tip-Edge philosophy of treatment. During the fall semester these patients are the only patients being seen by first year residents. The philosophy of this assignment is that fixed appliance therapy is the "bread and butter" of private orthodontic practice and a solid grounding in basic diagnosis and treatment planning is necessary to produce a competent orthodontist. It is hoped that by December of the first year the resident will have these 50 cases well under control and treatment will be in progress. The core clinic half-days are Monday, Tuesday, Wednesday, and Thursday mornings and afternoons.
In addition to the clinical instruction gained by treating patients in these core clinics, a companion seminar serves to provide the main avenue for didactic teaching of clinical orthodontics. This core seminar is for first and second year residents. The seminar meets the first hour of the clinic half-day. During the first year, a series of lecture topics is presented by the core clinic faculty. Following this, the second year of the seminar is devoted to case review. The first part of the case review involves a review of selected cases that are currently being treated in the core clinic. This portion of the second year seminar is termed Problem Case Review. Following the Problem Case Review, the remaining seminar time is devoted to the review of certain selected case types drawn from the core instructor’s private practice. A discussion of treatment mechanics as well as treatment philosophy completes the core instruction in clinical orthodontics. For third year residents this seminar concentrates on review of their own finished cases with their assigned faculty advisor.
After the semester break, the first year residents are introduced to the "sub-specialty" areas of orthodontic practice. These areas are introduced on a lecture basis during the fall in preparation for beginning clinical training in these disciplines in January. An additional 10 cases are assigned to the first year residents in January to be seen in the sub-specialty clinics. Treatment of cases within the sub-specialty clinics continues for 4 semesters beginning in January of the first year. The breakdown of the 10 sub-specialty starts is as follows:
Each resident is available to render treatment for patients with a variety of craniofacial anomalies. Training in diagnosis and treatment planning of patients is provided by resident participation in the Craniofacial Defects Clinic at Rainbow Babies and Children's Hospital (RB&C). This clinic meets twice a month to evaluate patients and recommend treatment and is the source of all patients seen in the orthodontic clinic. The RB&C clinic is comprised of specialists in the fields of Plastic Surgery, Maxillofacial Surgery, Pediatrics, Pediatric Dentistry, ENT, Speech and Hearing, Child Development, and Maxillofacial Prosthodontics. Residents assist the orthodontic specialist assigned to the team in the evaluation of patients. The resident also attends the summary conference where all the involved specialties discuss the treatment plans for the patients seen that day in the craniofacial clinic. Approximately 30 patients are seen in the evaluation clinic each month. In addition to these seminars, a one-semester didactic lecture course taught by the various specialists on the team is given in the fall of the first year and serves as an introduction to the clinical portion of the training. In this way the resident sees how each specialist evaluates a patient in the CFA clinic. Treatment of patients with craniofacial anomalies is coordinated by attending full-time faculty in the orthodontic department. Following the medical model, residents participate in care of these patients in a one-to-one tutorial with the attending doctor.
Modern orthodontic diagnosis and treatment planning divides malocclusions into skeletal and dental components. Given that orthopedic alteration of the growing face is both possible and desirable, some malocclusions can best be treated in the mixed dentition when considerable skeletal growth remains. The early treatment clinic is designed to give our residents experience in treating skeletal problems during the mixed dentition. This clinic begins during January of the first year with the assignment of three new patient starts for each resident. A variety of skeletal problems are treated in this clinic, including transverse maxillary deficiency, maxillary skeletal retrognathia, maxillary skeletal prognathia, mandibular skeletal retrognathia, mandibular skeletal prognathia, and vertical facial dysplasia. Instruction in this clinic takes the form of clinical case presentations by the attending instructors as well as actual treatment of patients. Because multiple phases of treatment are generally required to bring a case to completion, meticulous records are kept on all patients being treated and the review of the records is a major teaching resource in this clinic. Didactic instruction in the use of orthopedic forces and appliances begins during December of the first year. This coincides with the completion of the first semester of the didactic course in facial growth and development. Beginning this course in January gives the resident both a clinical and scientific basis for understanding the treatment modalities applied in this clinic. A patient that has completed the first phase of treatment will most likely be assigned to the core clinic for the fixed phase of treatment. In certain instances the patient may be assigned to the orthognathic surgery sub-specialty clinic if a significant skeletal discrepancy still exists at the completion of skeletal growth.
The adult treatment clinic concentrates on the special problems associated with the mature dentition. Each resident is assigned two new case starts after January of the first year. These patients are selected based on their need for interdisciplinary treatment. Special consideration is given to patients requiring combined periodontal, restorative and orthodontic treatment. This sub-specialty clinic involves orthodontic residents, advanced education in restorative dentistry residents, periodontic residents, and endodontic residents. A companion seminar is given along with the clinic to highlight relevant literature, provide a forum for case discussion, and provide time for instructors to present treated cases. Topics to be covered include: lingual appliances, treatment of periodontally involved patients, implants, and timing of interdisciplinary treatment.
The orthognathic surgery clinic is designed to treat mature patients with combined orthodontic and skeletal deformities. The clinic begins during January of the first year. In addition to clinical patient care, a series of didactic lectures are given to acquaint the resident with the departmental philosophy of combined orthodontic and surgical treatment. In January each resident is assigned two patients with combined dental and skeletal deformities. These cases are diagnosed and treatment planned in conjunction with the Department of Oral and Maxillofacial Surgery. In addition, approximately 40 patients will be currently under active treatment in the clinic. Additional experience in the immediate pre- and post-operative care of surgical patients is provided in the faculty practice clinic where residents assist full-time faculty attendings in the care of patients. Experience in clinical treatment is supplemented by weekly seminars in diagnosis and treatment planning, as well as case presentations by the instructors in the sub-specialty clinic. As part of their training, each third year resident spends two days on service in the Department of Oral and Maxillofacial Surgery. The purpose of this rotation is to give the resident experience in the hospital setting as well as in operating room protocol and procedures. In addition, each resident attends at least one surgical procedure on their own patients during their 24-month training in this clinic. To supplement the clinic and seminars the residents also may attend rounds at the hospital on Monday afternoons with the surgical residents.
Understanding the expanding role of the orthodontist in the diagnosis and management of occlusal disharmony, this clinic acquaints the resident with the orthodontic management of patients presenting with signs and symptoms of TMJ dysfunction. As with the other sub-specialties, the clinical portion of the training begins in January of the first year with the assignment of two new patient starts. The resident does a complete diagnosis and treatment plan for these patients and presents the findings in a seminar format. Additional experience in evaluating patients with signs and symptoms of TMJ dysfunction is gained by monthly participation in a TMJ diagnosis clinic. Every two months, approximately 5 new patients are evaluated in the diagnosis clinic. This gives the resident a chance to see a variety of TMJ problems and to sharpen their diagnostic acumen. In addition to the clinical treatment of patients, the resident also receives didactic instruction in diagnosis and clinical management of patients with TMJ dysfunction. Didactic instruction begins in late November of the first year to prepare the resident for the clinical experience. A pair of two-day continuing education seminars cover the following topics: Concepts of occlusion; Anterior guidance; Condylar position; Centric relation registration; TMJ diagnosis and treatment planning; Construction of a centric relation occlusal splint; and Construction of a protrusive positioning splint. In addition to these lectures, a companion laboratory course covers clinical equilibration, mounting casts on a fully adjustable articulator, and splint construction. Lectures and case presentations are also given by orthodontists actively involved in treating patients with dysfunctional occlusal conditions.
Along with the need to train residents in the art and science of orthodontics, there is a need to assess the quality of orthodontic education being provided at CWRU. To ensure a minimum standard of competence in clinical orthodontic treatment, each resident is required before graduation to finish 25 full-treatment orthodontic cases that he/she has started or has provided the majority of active treatment. In addition, a comprehensive clinical examination is given as a final evaluation of clinical competence. Because of the recent interest in specialty certification in orthodontics and because one of the goals of our department is to produce board qualified orthodontists, the final examination for clinical competence is patterned after the American Board of Orthodontics examination. Three completed orthodontic cases are selected by the second year resident to be presented along the guidelines published by the American Board. These three cases are displayed in the Enlow/Gould Seminar Room during the last week in October. An outside examiner selected by the chairman examines the cases. The pre-treatment records of two additional cases will be given to each candidate for their review and treatment plan. A one-hour oral examination will cover the three cases presented by the resident plus two additional treatment planning cases and didactic material presented in the program. A passing grade is necessary to complete the requirements for graduation. In addition, all residents are required to take the Phase 2 examination given by the American Board of Orthodontics at the annual session of the American Association of Orthodontists. Residents usually sit the examination in May of the second academic year of the program. Additional evaluations will apply and will be explained at the beginning of the program.
The department has an ongoing commitment to maintain its leadership role in the area of research. Each resident is encouraged to select his/her own research topic for his/her Master's thesis. The thesis is to be submitted in partial fulfillment of the Master's degree and should be completed within the first 24 months of the program. The department does not award a certificate degree and, therefore, all residents are required to produce a Master's thesis. In addition to producing a thesis document, each resident is required to submit as an appendix to the thesis a finished article suitable for publication in a refereed journal. Inclusion of the final draft of the article in an appendix to the thesis is required to complete the Master's program. The article need only be submitted for publication, not accepted, to fulfill the requirement for graduation. Up to $1,500 in research support from the School of Dental Medicine is available for each resident during his/her second year of study. Additional funds from the American Association of Orthodontists Foundation are also available to support resident research.
Specific areas of ongoing research in the department include:
The department functions as a community resource on two levels. First, the treatment of patients within the orthodontic clinic is recognized as a significant community service. The marketing of the orthodontic department to the surrounding community has increased the number and quality of patients being treated in the clinic. Increased visibility in the media and recognition of the department as an outstanding source of quality orthodontic care is essential. We strive to be self-sufficient financially and do not rely solely on resident tuition for departmental support.
In addition to an expanding role in community service, the department acts as an educational resource for the surrounding professional community. To this end we have instituted a visiting lecture series sponsored by the department. Lecturers are brought in approximately every four months to discuss relevant topics in the field of orthodontics. This lecture series is open to all members of the dental community, although special emphasis is placed on inter-specialty meetings and the lectures are advertised to dental specialists and university affiliated persons.
The Department of Orthodontics may be reached at 216.368.4649.
Dr. J. Martin Palomo, Program Director
Dr. J. Martin Palomo is the Director of the Orthodontic Residency and the Director of the Craniofacial Imaging Center at Case Western Reserve University in Cleveland, Ohio. His contributions in craniofacial imaging and informatics have been recognized through research awards in both medical and dental fields. Dr. Palomo is a director of the International Association of Dental Research Craniofacial Biology group, member of ADA and AAO technology committees, and is currently the chair of the AAO Committee on Technology. He is a board certified orthodontist, and an active member of both the Orthodontics and the Oral and Maxillofacial Radiology Associations.
J. Martin Palomo DDS, MSD
CWRU School of Dental Medicine