Special Article

Brazilian Board of Orthodontics and Facial

Orthopedics: Certifying excellence
Roberto M. A. Lima Filho*, Carlos Jorge Vogel**, Estélio Zen***,
Ana Maria Bolognese****, José Nelson Mucha*****, Telma Martins de Araújo******

Abstract

The Brazilian Board of Orthodontics and Facial Orthopedics (BBO) is the institution that certifies
the standards of clinical excellence in the practice of this specialty. This article describes the his-
tory of BBO’s creation and the examination structure and phases to obtain the BBO Certification.
It also presents a detailed report of the first exam applied in Brazil. Its purpose is to expand the
knowledge, among professionals in the area, about the importance of BBO Certification as assur-
ance of the highest level of quality in orthodontic treatments.

Keywords: Examination. Certification. Orthodontics.

The advances in medical sciences in the be- Since then, this new concept extended to
ginning of the 20th century positively affected other specialties. In dentistry, orthodontics was
the practice of specialties. Although such ad- the first to establish its Board. In July 1929, dur-
vances promoted improvements in service qual- ing the 28th Conference of the American Soci-
ity, there was no system to ensure, for the pa- ety of Orthodontics in the USA, the American
tient, that the professional that advertised as Board of Orthodontics (ABO) was founded.2
a specialist was actually qualified. Therefore, In 1950, the Council on Dental Education of
in 1908, Derrick T. Vail, then President of the the American Dental Association (ADA) recog-
American Academy of Ophthalmology and nized the ABO as the official certifying agency
Otolaryngology, came up with the concept of a for excellence in orthodontics.3
Board for specialties in health care.1 Essentially, In Brazil, the idea of creating a Board was also
a Board evaluates the knowledge and clinical born from the need to promote the achievement
skills of professionals in a certain specialty. In of clinical excellence standards in the practice of
May 1916, the pioneering American Board of orthodontics. In 1998, the Brazilian Association
Ophthalmic Examination was founded. of Orthodontics and Facial Orthopedics (ABOR),
How to cite this article: Lima Filho RMA, Vogel CJ, Zen E, Bolognese AM, » The authors report no commercial, proprietary, or financial interest in the
Mucha JN, Araújo TM. Brazilian Board of Orthodontics and Facial Orthopedics: products or companies described in this article.
Certifying excellence. Dental Press J Orthod. 2011 July-Aug;16(4):148-57.

* Post Graduate Degree in Orthodontics, University of Illinois at Chicago. MSc and PhD in Orthodontics, Federal University of Rio de Janeiro, Rio de Janeiro,
Brazil (UFRJ). Diplomate of the American Board of Orthodontics. Former President of the Brazilian Board of Orthodontics and Facial Orthopedics (BBO).
** MSc, University of Illinois, Chicago, USA. PhD in Orthodontics, University of São Paulo (USP), São Paulo, Brazil. Member of the Angle Society of Ortho-
dontics. Former President of the Brazilian Board of Orthodontics and Facial Orthopedics (BBO).
*** Post Graduate Degree in Orthodontics, UFRJ. MSc in Orthodontics, UFRJ. Former President of the Brazilian Board of Orthodontics and Facial Orthopedics (BBO).
**** MSc and PhD in Orthodontics, UFRJ. Specialist Degree in Radiology, UFRJ. Full Professor, Orthodontics, UFRJ. Former President of the Brazilian Board
of Orthodontics and Facial Orthopedics (BBO).
***** MSc and PhD in Dentistry, UFRJ. Specialist Degree in Radiology, UFRJ. Full Professor, Orthodontics, Fluminense Federal University (UFF), Rio de Janeiro,
Brazil. Former President of the Brazilian Board of Orthodontics and Facial Orthopedics (BBO).
****** MSc and PhD in Orthodontics, UFRJ. Full Professor and Head of the Orthodontic Center “Professor José Édimo Soares Martins”, Federal University of
Bahia, Salvador, Brazil. Specialist Degree in Radiology, UFRJ. Former President of the Brazilian Board of Orthodontics and Facial Orthopedics (BBO).

Dental Press J Orthod 148 2011 July-Aug;16(4):148-57

 Lima Filho RMA, Vogel CJ, Zen E, Bolognese AM, Mucha JN, Araújo TM

presided by Eros Petrelli, established a Special Similarly to what occurred in the United States,
Committee, whose members were Kurt Faltin Jr., the BBO had a pioneering role in health care in
Roberto Mario Amaral Lima Filho and Airton O. Brazil and acted as an exemplary model for other
Arruda. In 1999, during the 2nd ABOR Meeting, specialties in dentistry and medicine.
a project to create the Brazilian Board was dis- The BBO Board of Directors has eight
cussed and evaluated during the ABOR Council members: President; President-elect; Secretary;
Meeting, and its principles were approved by all Treasurer; 1st Director; 2nd Director; 3rd Di-
council members. rector; and 4th Director. The Directors serve
In May 2000, members of the ABOR Special one-year terms. After that, the President leaves
Committee participated in a meeting of the ABO his position, becomes a member of the group
in Chicago, USA, to learn about the operations of former presidents and retains membership.
of the American Board. The event was directed The President-elect then becomes President
to countries interested in the implementation of and, sequentially, the other members are ap-
a certification system. The essential resources to pointed to the immediately higher position.
operate a Board were available and provided by The 4th Director position becomes vacant and,
the ABO Directors. The Brazilian Committee es- on the same date, a new member for that posi-
tablished contacts to learn about the mechanisms tion is elected by the General Assembly. This
necessary to establish the Brazilian Board and re- model gives the members the chance to be-
ceived full support and promises of effective as- come familiar with all the institutional struc-
sistance. The material resulting from this meeting tures and prepares and motivates the Directors
was presented in an extraordinary meeting of the acting in the different positions.
ABOR during the Orto Rio Premium Conference The candidates to obtain the certification as
in Rio de Janeiro in July 2000. “Diplomate of the Brazilian Board of Orthodon-
The professionals appointed to participate in tics and Facial Orthopedics” are evaluated in the
the first Brazilian Board were: Roberto Mário areas of diagnosis, treatment planning and knowl-
Amaral Lima Filho, Carlos Jorge Vogel, Fran- edge about different aspects of orthodontic treat-
cisco Damico, Estélio Zen, Anna Letícia Lima, ments. The examinations provide a unique op-
Ana Maria Bolognese, José Nelson Mucha and portunity for candidates to review their practices,
Telma Martins de Araújo. The legitimacy to reflect about the importance of carefully main-
hold those positions was obtained in examina- taining quality records, of mechanical control in
tions applied during the 101st Meeting of the performing the treatment and of the attention to
American Association of Orthodontics (AAO) the final treatment phase.
held in Toronto, Canada, on May 7, 2001. On To ensure the continuous professional qual-
that occasion, the members of the group were ification and recycle his or her clinical skills
examined by Dr. Jack Dale and Dr. Eldon Bills, and scientific knowledge, the BBO diplomate
former ABO presidents. must undergo periodic revalidation of the Cer-
The Brazilian Board of Orthodontics and Facial tificate of Excellence.
Orthopedics (BBO) was founded on September 2, Another relevant aspect of the certifica-
2002, in São Paulo. The founding members were tion is professional ethics. The professionals
Roberto Mário Amaral Lima Filho, Carlos Jorge that decide to seek certification are moved by
Vogel, Estélio Zen, Ana Maria Bolognese, José an ideal and dedication to their profession. Be-
Nelson Mucha and Telma Martins de Araújo, who ing granted is indicative of determination and
also participated on the first Board of Directors. merit. However, the certificate issued by the

Dental Press J Orthod 149 2011 July-Aug;16(4):148-57

Brazilian Board of Orthodontics and Facial Orthopedics: Certifying excellence

Board does not grant any professional license or Examination

academic degree. It is a certificate of excellence The BBO certification examination has two
and, therefore, does not confer any privileges in phases. Phase 1 is the evaluation of the diagno-
the practice of orthodontics. The best definition sis and planning of cases presented by the BBO;
of the feelings of professionals that seek certi- phase 2, the presentation of ten cases treated by
fications came from the American orthodon- the candidate.4 The cases presented in phase 2
tist George Ewans: “The title conferred by the should meet the following criteria: 1) Angle Class
Board will not make you better than others, but II or III malocclusion treated without extractions
it will definitely make you better than before.” and with growth control; 2) Angle Class I maloc-
clusion treated with extractions of permanent
Symbols teeth; 3) Angle Class II malocclusion treated with
The BBO logo was developed using a classi- extractions of permanent teeth; 4) Malocclusion
cal lettering style, which conferred a tradition- with marked anteroposterior discrepancy: Angle
al character to this symbol, compatible with Class III relationship and ANB angle equal to or
the status of an agency that certifies profes- smaller than -2 degrees; Angle Class II relationship
sional excellence. The figure that accompanies and ANB angle equal to or greater than 5 degrees;
the lettering suggests smoothness and stands 5) Malocclusion with transverse discrepancy and at
for the concept of non-traumatic correction: least one quadrant with crossbite; 6) Malocclusion
a plant shoot being guided to grow up. As an and marked overbite; 7 to 10) free choice.
analogy, this image refers to the aim of our pro-
fession (orthodontic correction), to the pro- Orthodontic records
fessional practice per se and the educational Good quality orthodontic records are essential
guidelines in the area. The colors are referenc- for an accurate diagnosis, which is, in turn, key
es to the Brazilian flag. The seal has the tradi- to the success of orthodontic treatment. Records
tional shape of a stamp, and keeps the logo in should be identified using letters and colors: A
an outstanding position. This logo is also print- – beginning of the treatment (black); A1, A2 –
ed on the lapel pin that all Diplomates receive intermediate (blue); B – end of treatment (red);
when certification is granted (Fig 1). and C – post treatment (green). The records for

BBO
Board Brasileiro
de Ortodontia
e Ortopedia Facial

A B C

FigurE 1 - BBO symbols: A) Logo; B) Seal and C) Lapel pin.

Dental Press J Orthod 150 2011 July-Aug;16(4):148-57

 Lima Filho RMA, Vogel CJ, Zen E, Bolognese AM, Mucha JN, Araújo TM

the end of treatment (B) may be obtained up to be limited to removing bubbles and small flaws.
one year after the appliance is removed. Changes in tooth anatomy are considered adul-
To ensure that evaluations are uniform and terations, which will lead to the automatic rejec-
balanced, records should be standardized. The tion of the case. Dental casts must be polished
cases submitted should include dental casts, radio- so that all anatomic details are preserved (Fig 3).
graphs and photographs. The requisites for dental When preparing casts for cases in which it is not
cast trimming and the cephalometric evaluation possible to use the recommended heights and an-
(tracing, angles, linear measures and superimposi- gles, symmetry, proportion and esthetics should
tions) follow international norms for case presen- be taken into consideration.
tations and are available in the BBO website.
Radiographs
Dental casts Panoramic, periapical and supplemental ra-
Casts should accurately reproduce dental diographs should be of good quality. The films
arches and the buccal area to serve as accurate should be accurately oriented, and the right
models of the malocclusion. The casts should and left sides should be marked. Panoramic ra-
be trimmed to maximum intercuspation, as diographs without a satisfactory definition in
shown in Figure 2.5 the incisor areas (maxillary and mandibular)
Adjustments or trimming in the anatomic por- should be accompanied by periapical radio-
tion (teeth and buccal area) of the casts should graphs of these areas (Fig 4).

FigurE 2 - Initial dental casts of Class II malocclusion case, accurately trimmed.5

Dental Press J Orthod 151 2011 July-Aug;16(4):148-57

Brazilian Board of Orthodontics and Facial Orthopedics: Certifying excellence

FigurE 3 - Polished casts with preserved details and accurate reproduction of malocclusion.

A B

FigurE 4 - Panoramic radiograph (A) and periapical radiograph of maxillary and mandibular incisors (B).

Lateral cephalometric radiographs should be The patient’s name and the radiograph date
properly standardized, and bone and soft tissue should be visible.
profiles should be clearly visible. In cases of evi- Cephalograms should be carefully hand-
dent facial asymmetry posteroanterior cephalo- traced by the examinee on tracing acetate using
grams should be properly examined and submit- a 0.5-mm diameter pen or pencil. They should
ted in addition to profile cephalograms (Fig 5). To contain only the anatomic details of interest for
preserve anonymity, the names of the radiology clinical analysis and cephalometric superimposi-
service and of the dentist should be blacked out. tions (Fig 6). Computer-generated tracings are

Dental Press J Orthod 152 2011 July-Aug;16(4):148-57

 Lima Filho RMA, Vogel CJ, Zen E, Bolognese AM, Mucha JN, Araújo TM

A B

FigurE 5 - Lateral (A) and posteroanterior (B) cephalometric radiographs.

respective supporting bones. Total superimposi-

tions may be prepared using one of two methods
SNA
SNB (Fig. 7): (a) Plane of the sphenoid bone and eth-
ANB
moid cribriform plate, registered on the midpoint
Facial Convex.
FMA Y axis
between the wings of the sphenoid bone; and (b)
the sella-nasion plane, registered on sella. Partial
1NA ang
Ls-S superimpositions should be prepared as follows
SN-GoGn 1:1 1NA mm (Fig 8): Maxilla – best fit of the maxillary bony
1NB mm
1NB ang
1 -APog Li-S complex, registered on the palatal curve; mandible
IMPA – best superimposition in the lower limit of the
cortical bone of the mandibular body, registered on
FigurE 6 - Cephalometric tracing with reference lines and indication of
the internal cortical outline of the symphysis.
places where measurements should be included. The three superimpositions should be hand-
traced by the examinee using pen or pencil. In
not accepted. Templates may be used to trace cases of treatments with intermediate tracings,
tooth outlines. Cephalometric landmarks should superimpositions should be presented as follows:
be carefully identified to ensure reliability of the A-A1 (beginning–intermediate), A1-B (inter-
reference lines drawn. mediate–final) and A-B (beginning–final). Cases
The examinee should be familiar with all as- with post-treatment records should include A-B-
pects of cephalograms, tracings and measurements, C (beginning–final–post-treatment). Superimposi-
as well as their meanings. Tracings should be sepa- tions should be arranged on white paper, but not
rated from the lateral radiographs and placed in fixed to it, and placed into separate envelopes. In
the plastic envelopes found in the folders. cases treated with orthognathic surgery, presurgi-
At least three tracing superimpositions are re- cal intermediate tracings should be included.
quired: Total or craniofacial, to evaluate general
changes during growth and/or treatment; and par- Photographs
tial, maxillary and mandibular, to demonstrate den- Patient records should include the following face
tal changes in the maxilla and mandible and their photographs: (a) Frontal; (b) Right lateral profile;

Dental Press J Orthod 153 2011 July-Aug;16(4):148-57

Brazilian Board of Orthodontics and Facial Orthopedics: Certifying excellence

A B

FigurE 7 - Total superimpositions: A) Plane of the sphenoid bone and ethmoid cribriform plate, registered on the midpoint between the wings of the
sphenoid bone; B) the Sella-Nasion line, registered on Sella.

A B

FigurE 8 - Partial superimpositions: A) Maxilla – best fit of the maxillary bony complex, registered on the palatal curve; B) Mandible – best superimposition
in the lower limit of the cortical bone of the mandibular body, registered on the internal cortical outline of the symphysis.

and (c) whenever possible, a frontal smile pho- purposes of orientation; the eyes should be open
tograph. These photographs should be oriented and looking straight ahead; glasses and other ac-
to Frankfort horizontal, and the line between cessories should be removed.
the pupils should be parallel to the ground. They In addition to facial photographs, each case
should be taken with relaxed lips and depict the should include at least three intraoral records: a
patient’s actual labial relationship. frontal view, a right lateral view, and a left lateral
The background should be neutral, preferably view, all with teeth in maximum intercuspation.
white; good-quality lighting should reveal facial con- These photographs should be oriented to the occlu-
tours without shadows; the ears should be visible for sal plane. Optional photographs may be included,

Dental Press J Orthod 154 2011 July-Aug;16(4):148-57

 Lima Filho RMA, Vogel CJ, Zen E, Bolognese AM, Mucha JN, Araújo TM

such as occlusal views of the maxillary and mandib- they should accurately demonstrate soft and hard
ular dental arches. Photographs should be as close tissues. Photographs may be printed in color to
as possible to a 1:1 ratio with the patient´s teeth. achieve the best possible framing, using the land-
If mirror images are used, they should be printed scape layout and printing them on glossy photo
vertically fliped. Attention should be paid to a few paper. The examinees should keep in mind that
other aspects: clean teeth, free of bacterial biofilm, records are legal documents and must not be al-
bleeding or saliva; cheek retractors; adequate light- tered. For malocclusions with marked skeletal
ing to show anatomic contours, completely free of discrepancies and indication of orthodontic treat-
shadows; standardized colors; no visual distractions ment associated with orthognathic surgery, im-
(cheek retractors, labels, fingers). mediate preoperative records must be submitted.
If the facial and intraoral images are computer Below an example of a photo mount with three
generated, their resolution should be high, and facial and five intraoral photographs (Fig 9).

A B C

Patient B
Age
Date

D E

F G H

FigurE 9 - Photograph layout: A, B, C) facial - right-side profile, frontal and frontal smiling photographs; D, E, F, G, H) intraoral - upper occlusal, lower
occlusal, right lateral, frontal and left lateral photographs.

Dental Press J Orthod 155 2011 July-Aug;16(4):148-57

Brazilian Board of Orthodontics and Facial Orthopedics: Certifying excellence

First examination presentation was identical to the others. How I

BBO conducted its first examination from wish that this standard of excellence existed all
March 19 to 21 in 2004, in the city of São Pau- over the world.
lo, Brazil. Interestingly, in that same year, the The exam was divided into two parts: (a) a
American Board celebrated its 75th anniversary. written exam about case reports presented by
The examination had the special participation the BBO; and (b) case report displays by each
of Jack Dale, renowned Canadian orthodontist, examinee.
former ABO president and Professor Emeritus a) Written examination: examinees from
of the University of Toronto. In May of the same eight Brazilian states had four hours to
year, during the 104th AAO Annual Session in examine two cases presented by BBO. For
Orlando, Florida, Jack Dale was honored for his that, they were allowed to make cephalo-
services to the American Board. At that time, metric tracings and carry out any proce-
he mentioned the work of the BBO Board of dures that they used in their practices. I
Directors and highlighted the effort and hard sat in the room for the four hours allotted
work that were landmarks of the beginning of for the examination, and observed men
the journey into BBO’s mission.6 In special ref- and women working hard at their tasks.
erence to it, he delivered a speech, freely repro- The more I observed them, the more my
duced below, which translated his view of the admiration and respect grew.
integrity of the Board efforts in Brazil: B) Case report displays: the ten cases submit-
The California redwoods, as magnificent as ted by each examinee included six with
they are, do not grow alone; they need each other. specific malocclusions and four optional.
They grow strong together by intertwining and en- The cases were on display in the room to
tangling their roots, thus supporting one another. be examined for two days. After that, there
Without this mutual support they could not be was a round table with the participation of
nearly as robust and magnificent. With mutual sup- all the examinees. The discussion was most
port, we can remain strong and effective in our ser- valuable and constructive for the BBO.
vice to society. Maintaining our standard of care is a The motto on the Brazilian flag means “Or-
vital part of our strength… all over the world. der and Progress”. BBO exemplified this motto to
It was my honor and privilege to be invited as perfection. They certainly achieved progress and
an external consultant for the first BBO examina- did it step by step in an orderly way.
tion. I found the treatment to be superb and the
organization by the board of directors outstand- FINAL CONSIDERATIONS
ing. There were problems, but that was expected. The awareness of the relevance of professional
I am sure that these problems will be dealt with qualification should be developed and expanded,
and solved in the future, because I am aware of as it occurs in the USA, where this movement has
the integrity, dedication, competence and con- been constant in the different specialties. BBO is
cern of the BBO Directors. The American Board synonymous of qualification and adequate train-
of Orthodontics has also had to solve problems ing to perform a successful treatment. Its creden-
along its 75 years of existence. In the future, these tials confirm professional competence and assure
problems will certainly remain challenges. that the patient will receive a safe and efficacious
In Brazil, records were standardized, uniform treatment. Therefore, it should be used as motiva-
and beautifully done. You could examine any tion for other professionals to seek excellence in
of the case reports on display and find that the Orthodontics and Facial Orthopedics.

Dental Press J Orthod 156 2011 July-Aug;16(4):148-57

 Lima Filho RMA, Vogel CJ, Zen E, Bolognese AM, Mucha JN, Araújo TM

As Jack Dale said, the motto on the Brazil- believe in such effort so that the seed sown by
ian flag was put into practice by BBO. Accord- the words of the Canadian professor germinates
ing to that prominent professional, the level of and bears good fruit as more specialists apply for
excellence was achieved in the organization of excellence certification by the Brazilian Board of
the examination structure, which makes Brazil Orthodontics and Facial Orthopedics. The BBO
stand out as a model for the countries aspiring certification system has been constantly updating.
to become members of the World Board of Or- Therefore, orthodontists interested in taking the
thodontics (14 countries already have a Board Certification Examination should regularly check
of Orthodontics). Brazilian professionals should the website www.bbo.org.br.

ReferEncEs

1. Little DM. The founding of the specialty boards.

Anesthesiology. 1981;55:317-21.
2. Cangialosi TJ, Riolo ML, Owens S Jr, Dykhouse VJ, Moffitt
AH, Grubb JE, et al. The American Board of Orthodontics
and specialty certification: the first 50 years. Am J Orthod
Dentofacial Orthop. 2004;126(1):3-6.
3. The American Board of Orthodontics. [Cited 2010 Jan 11].
Available from: www.americanboardortho.com.
4. Board Brasileiro de Ortodontia e Ortopedia Facial. [Acesso Submitted: June 13, 2011
Revised and accepted: July 3, 2011
2010 Jan 11]. Available from: www.bbo.org.br.
5. Habib F, Fleischmann LA, Gama SLC, Araújo TM. Obtenção
de modelos ortodônticos. Rev Dental Press Ortod Orthop Contact address
Facial. 2007;12(3):146-56. Roberto M. A. Lima Filho
6. Dale J. Brazilian Board of Orthodontics and Dentofacial Avenida Alberto Andaló 4.025
Orthopedics holds first examination. Am J Orthod CEP: 15.015-000 – São José do Rio Preto/SP, Brazil
Dentofacial Orthop. 2004;126:134. E-mail: rlima@me.com

Dental Press J Orthod 157 2011 July-Aug;16(4):148-57