PLAN What methods have been used to evaluate the treatment need and outcome in orthodontics.

Describe contemporary indices known to you and their use. Orthodontic indices Discuss/introduction to the indices related to ortho treatment General requirements of an index Types of index Occlusal

Angles / molar Incisor

Skeletal Class I, II and II Malocclusion Occlusal index HMAR IOTN ICON

Treatment assessment Littles irregularity index PAR Cleft lip and palate outcomes Goslon yardstick 5 year olds index Periodontal Plaque index Gingival index Dental Tooth wear index

What methods have been used to evaluate the treatment need and outcome in orthodontics. Describe contemporary indices known to you and their use. Elaine Brough General requirements of an orthodontic index When patients are assessed with regard to their need for orthodontic treatment and the outcome following their orthodontic treatment an index should be used. In order for the patients to be assessed the index should be contain the following general characteristics, it should be Reliable Valid Acceptable to profession and public Require minimal judgement Be administratively simple

Within the orthodontic literature there are several indices available which record malocclusion. They can be sub divided into those which; 1) 2) 3) 4) 5) Classify the malocclusion Describe the prevalence of the malocclusion Describe need/priority for orthodontic treatment Record/ score treatment success Record treatment difficulty

There are many orthodontic indices used, however it is important to distinguish between those which determine need and priority for treatment from those which simply classify the malocclusion (Brook 1989). The following types are more accurately described as classifications rather than indices, as they classify features of a malocclusion. Occlusal classifications These indices/classifications are used at the initial assessment of our patients, they form part of the assessment in which patients are assessed for need for treatment and treatment complexity.
Angles classification - molar relationships Angle 1899

Class I Class II Class III

MB cusp of upper 6 occludes with buccal groove of lower 6 MB cusp of upper 6 is at least 1 cusp width mesial to class 1 MB cusp of upper 6 is at least 1 cusp width distal to class 1

They can also be divided into and units (class II/III)

 Incisor classification British standards Institute 1983 - incisor relationship

Class I lower inc edges lie on/ immediately below the cingulum plateau Class II/i lower inc edges lie post to cingulum plateau + OJ is increased, upper incisors are usually proclined Class II/ii lower inc edges lie post to cingulum plateau + OJ is minimal or may be increased, upper incisors are retroclined Class III lower incisors lie ant to cingulum plateau, OJ is reduced/ reversed
skeletal classification Houston et al 1993 Class I ANB 2-4 degrees Class II ANB greater than 4 degrees Class III ANB less than 2 degrees

Other general indices are also important when planning orthodontic cases, these may form part of the initial examination of a patient, with regard to the need and suitability for treatment, they include; Periodontal indices Plaque index Gingival index stillness and Loe 1964 stillness and Loe 1963

The plaque index assesses plaque presence 0= no plaque at gingival margin 3 = heavy accumulation of plaque on the teeth. Plaque scores of <10% are compatible with commencing orthodontic treatment. The gingival index assesses and records gingival condition from 0= healthy 3= severe inflammation and spontaneous bleeding. Dental indices Tooth wear index smith and knight 1984 - assesses pathological wear of teeth, this is scored on a scale of 0-4 from a clinical examination;
0= no wear present 4= pulpal involvement

When assessing a patient for their need for treatment it important that we understand the benefit for the patient from having orthodontic treatment. Perceived benefits from treatment include; Improved aesthetics Social-psychological well-being

 Dental health benefits It was suggested Brook & Shaw that an index which assesses the need for treatment must include all of the above aspects. The following are orthodontic indices which determine treatment need/ outcome commonly used Malocclusion indices (1) Index of treatment need (2) Handicapping malocclusion assessment record (3) Occlusal index (4) Index of treatment complexity, outcome and need The Index of Orthodontic Treatment Need (IOTN) Index of orthodontic treatment need is a clinical tool which is used to attempt to rank malocclusion, it is composed of two components, (1) The dental health component (2) The aesthetic component Development of the IOTN It was felt that the best way to assess orthodontic need was by using an index with two components, one aspect would assess dental health and function related to need for treatment and the other aspect assessed the aesthetic need for treatment Brook and Shaw 1989. The dental health component Patients are assessed and grouped into one of five groups numbered 1-5. Group one no need for orthodontic treatment and group 5, very great need for treatment. The dental health component was based on the index of treatment priority used by the Swedish dental board (Linder Aronson, 1974). A ruler is used and the most severe characteristic is scored They single worst feature is assessed in order of MOCDO Missing Overjet Cross bites Displacements Overbite

The aesthetic component This aspect scores impairment caused by the malocclusion. It uses 10 colour photographs which are scored 1-10, 1 equates to the most attractive image and 10 to the least attractive image, and therefore they rate dental attractiveness. The SCAN index (standardised continuum of aesthetic need) was used (Evans and Shaw 1987). The scale of 10 photos was selected by 6 non dental judges scoring 1000 12yr olds dental images using the VAS scale, representative images were selected at 0.5mm intervals along the VAS scale. A recent paper (Oliveira et al 2008 ) investigated whether IOTN could be improved by adding a health related quality of life (QoL) aspect to the index. In they work they concluded that adding a QoL measure did not alter the outcome of the consultation, but it explained the prediction of the need for appliances and that children with an impact on their QoL were currently denied treatment. Handicapping malocclusion assessment record (HMAR) This index is said to be simple with reasonable reproducibility, it can be done at the chair-side or on study models. The features of the malocclusion are scored and given points, there are weighting factors used. Occlusal index Complicated scoring system Scores dental age, molar relationship, overbite and overjet, posterior x bits and open bites, tooth displacements, centrelines and missing upper laterals. Reasonable reproducibility Reasonable validity summers 1971 Index of treatment complexity, outcome and need This index aims to assess treatment input and outcomes. The malocclusion is scored and this score is used to assess for need for treatment. Five occlusal traits are identified in the index of treatment complexity, outcome and need The total score indicates the need for treatment, the scores are weighted as follows; Component IOTN aesthetic component Crossbites Upper arch crowding and spacing Buccal segment AP relationship weighting 7 5 5 3

Anterior vertical relationship

Pre treatment models are scored and they assess treatment need they rank the case from easy to very difficult. Then post treatment models are assessed and these indicate treatment outcome., they rank the improvement in the case from not improve/ worse to greatly improved. This index was shown to have High validity Agreement with PAR in terms of treatment outcome Treatment assessment indices (1) Littles irregularity index (2) Peer assessment rating (PAR) Littles irregularity index Little 1975 This index assesses the irregularity of the lower labial segment. It scores the contact point displacements mesial to the canines in mm. These mm displacements are totalled and a summed displacement of the contact points of the mandibular teeth is calculated. Peer assessment rating The PAR index was developed to give a total score for a malocclusion, the score shows how far that occlusion deviates from the normal (Richmond et al). The PAR index is used to compare pre and post orthodontic treatment study models and gives a score for the outcome/ success of a case. It is based on assessment of study models and five components are assessed as shown in the table below. component Upper and lower anterior segments Left and right buccal segments Overjet Overbite centrelines weighting 1 1 6 2 4

Each aspect of the occlusion is assessed as shown above, and each feature is given a weight. This aspect of the index is thought to be a negative aspect as Overjet is highly weighted in the PAR index and carries a weighting of 6. Overbites have a low

weighting and there is no weighting for displacements. Which in turn means cases treated with larger OJ reductions are highly scored on the PAR index and crowding cases with normal overjets score much lower. The PAR index is used as an indicator of clinical outcome and was found to be; Reliable Uniform Standardised Other indices used are; Cleft lip and palate outcomes 1) 2) Goslon yardstick 5 year olds index

Goslon Yardstick (Mars et al 1987) This index assesses the outcome of unilateral CLP and measures the quality of facial growth and dental arch relationships. It is a study model index, using 10 yr olds models The surgical outcomes are ranked on their clinical success, the grouping corresponds to their clinical outcome; Group 1= excellent outcome Group 5= very poor outcome 5 year olds index (Atack et al 1997) This index again assesses clinical outcomes in unilateral CLP patients This is based on 5 year olds models, again is a study model index The ranking of the surgical outcomes in the following groups; Group 1= excellent outcome Group 5= very poor outcome To conclude the use of indices related to orthodontic treatment is important in assessing suitability for orthodontic treatment, need for treatment and outcome of their treatment. The index which is used should have high reproducibility, reliability and validity. Its vital that patients are assessed with respect to their need for treatment but also that we assess ours cases post debond, this should be done in a non bias way which ultimately improves treatment quality and can be used as part of audit and teaching.

When using an index to assess patients need, at present the use of indices are based on assessment of morphology, and are measured by occlusal indices or radiographic findings, future developments for the need for treatment may also involve the inclusion of socio dental measure when assessing need and outcome.

References Brook PH and Shaw WC (1989) The development of an index of orthodontic treatment priority. European Journal of Orthodontics 11; 309-320 Casko JS (1998) Objective grading system for dental casts and panoramic radiographs American board of orthodontics November 1998, 589-599. O'Brien KD, Shaw WC and Robert C (1993) The use of occlusal indices in assessing the provision of orthodontic treatment, by the Hospital Orthodontic Service of England and Wales. British Journal of Orthodontics 20; 25-35 Oliveira CM Sheiham A Tsakos G and OBrien KD(2008) Oral health related quality of life and the IOTN index as predictors of childrens perceived needs and acceptance for orthodontic treatment. BDJ 2008 :204 Pickering EA and Vig P (1976) The occlusal index used to assess orthodontic treatment. British Journal of Orthodontics 2; 47-51 Richmond S, Shaw WC, Stephens CD, O'Brien KD, Buchanan IB, Jones R, Roberts C and Andrews M (1992) The development of the PAR index (Peer Assessment Rating): Reliability and validity. European Journal of Orthodontics 14; 125-139 Salonen L, Mohlin B, Gtzlinger B and Helldn L (1992) Need and demand for orthodontic treatment in an adult Swedish population. European Journal of Orthodontics 14; 359-368 Evans MR and Shaw WC (1987) Preliminary evaluation of an illustrated scale for rating dental attractiveness. European Journal of Orthodontics 9; 314- 318