A Review of Orthodontic Indices: DR Alka Gupta, DR Rabindra Man Shrestha
A Review of Orthodontic Indices: DR Alka Gupta, DR Rabindra Man Shrestha
ABSTRACT
Orthodontic indices are essential component in assessing severity, complexity and treatment outcome of malocclusion.
Moreover, they are useful in evaluating treatment need, funding for treatment cost and public health aspects of orthodontic
treatment. The present article reviews orthodontic indices used for clinical and epidemiologic purposes. The article attempts
to classify the indices in qualitative and quantitative methods based on the description given by the respective authors. The
indices are presented in chronological order in tabular form.
The evaluation of malocclusion is the essential component 6. The index should also be simple, accurate and yield
in establishing the diagnosis and treatment need of the itself to modification for the collection of data.
orthodontic patient. One of the major problems in studying 7. The examination procedure should require a minimum
malocclusion is the availability of a suitable objective of judgment.
method for recording the occurrence and severity of 8. The index should be simple enough to permit the
orthodontic problem. Thus, orthodontic indices are used study of a large population without undue cost in
in clinical and epidemiological studies of malocclusion. time or energy.
The index comprise of numerical values describing the
9. The examination required should be performed
relative status of a population on a graduated scale
quickly, to evidence to a group variation.
with definite upper and lower limits, which is designed to
10. The index should be valid during time.
permit comparison with other populations classified by
the same criteria and methods.2 However, none of the Angle in 1899 classified malocclusion, after which
indices can be considered ideal for all purpose, accurate, numerous classification methods evolved. However,
valid and reliable for assessing the malocclusion for the qualitative methods of classifications were found to be
priority of treatment need, allocating limited resources not suitable for measuring the severity and treatment
and assessing treatment outcomes.3 needs. The WHO/FDI basic method recorded symptoms of
malocclusion with carefully defined criteria. This method
The objective of this article is to review the historical
was essentially derived from the principle developed for
aspects of various orthodontic indices, provide their brief
recording individual traits of malocclusion by Bjork et al.
description and to classify them.
Initially, occlusal indices were used as an epidemiological
Requirements of an ideal index (WHO)4
tool to rank or classify the occlusion. During 1950s and
1. Classification is expressed by a finite scale with 1960s, many occlusal indices were introduced. William
definite upper and lower limits; running by progressive Shaw and co-workers in 1995 classified occlusal indices
gradation from zero (absence of disease), to the into five following groups.
Angle (1899)8 • Malocclusion is classified into 3 distinct types based on molar relationship.
• Devised as a prescription for treatment planning.
• In 1992, Houston et al27 considered Angle classification as the only internationally
recognized classification mostly used in epidemiological studies.
• The index has been criticized by Graber (1972), Rinchuse (1988).28
Stallard (1932) 29
• General dental status, including some malocclusion symptoms are recorded
McCall (1944)30 • Include molar relationship, posterior crossbite, anterior crowding, rotated incisors,
excessive overbite, open bite, labo/linguo version, tooth displacement, constriction of
arches.
Sclare (1945)31 • Include Angle classification of molar relationship, arch constriction with/without incisor
crowding, superior protrusion with/without incisor crowding, labial prominence of canines,
lingually placed incisors, rotated incisors, crossbite, open bite and closed bite.
Index of Tooth Position • Displacement and rotation of the tooth are measured.
• The recorded data is used to evaluate the incidence and prevalence of malocclusion in
- Massler & Frankel (1951)11 population group.
Malalignment Index • Involve grading of the tooth displacement and rotation
• Quantitatively defines tooth displacement (<1.5 mm or >1.5mm) and tooth rotation ( <45o
- Van Kirk & Pennel (1959)12 or >45o)
Fisk (1960)32 • Dental age is used for grouping the patients.
• Three planes of space are considered:
1. Antero-postero relationship: Angle classification, anterior crossbite, overjet, negative
overjet
2. Transverse relationship: Posterior crossbite
3. Vertical relationship: Openbite, overbite
• Additional considerations include labio-lingual spread (Draker, 1960),17 spacing,
therapeutic extractions, postnatal defects, congenital defects, mutilation, congenital
absence, supernumerary teeth.
Bjork, Krebs & Solow (1964)6 • Objective registration of malocclusion symptoms based on detailed definitions.
• Data obtained could be analyzed by computers.
• Primarily developed for epidemiological purpose with little emphasis on treatment need.
• Following three parts are considered:
1. Anomalies of dentition: Tooth anomalies, abnormal eruption, malalignment of
individual teeth.
2. Occlusal anomalies: Deviation in the positional relationship between upper and
lower dental arches in sagittal, vertical and transverse plane.
3. Deviations in space conditions: Spacing or crowding.
Incisal categories • Also known as British Standards Institute Classification
• Considered more reliable to Angle classification as posterior teeth relation did not
Ballard & Wayman (1965)9 influence the incisor occlusion
• Based on the relationship of incisal edges of upper and lower incisors.
Five-point system • Five major characteristics of malocclusion are represented through a Venn diagram.
• Incorporates evaluation of crowding and asymmetry within the dental arches
- Ackerman & Proffit (1969)10 • Includes transverse, vertical and antero-posterior planes of space
• Incorporates information about skeletal jaw proportions
• Five-step procedure of assessing malocclusion:
1. Alignment: Ideal, crowding, spacing, mutilated.
2. Profile: Mandibular prominence, mandibular recession, lip profile relative to nose
and chin (convex, straight, concave).
3. Crossbite: Relationship of dental arches in the transverse plane, as indicated by
bucco-lingual relationship of posterior teeth.
4. Angle classification: Relationship of the dental arches in the sagittal plane
5. Bite depth: Relationship of the dental arches in vertical plane, as indicated by the
presence/absence of anterior/posterior open bite and posterior collapsed bite.
WHO/FDI method • Method of measuring occlusal traits developed by Federation Dentaire’ Internationale
(FDI) Commission on Classification & Statistics for Oral Conditions (COCSTOC).
- Baume et al (1979)15 • Aimed at developing a system of measuring occlusion which could be used widely with
the result being comparable.
• Five major groups are recorded as follows:
1. Gross anomalies
2. Dentition: Absent teeth, supernumerary teeth, malformed incisors, ectopic eruption
3. Spaced condition: Diastema, crowding, spacing
4. Occlusion:
a. Incisor segment: Maxillary/mandibular overjet, overbite, openbite, crossbite
b. Lateral segment: antero-posterior relations, open bite, posterior crossbite
5. Orthodontic treatment need judged subjectively: Not necessary, doubtful,
necessary.
Memorandum of • Proposed by Danish National Board of Health to assess orthodontic treatment need
Orthodontic Screening &
Indications for Orthodontic
Treatment (1990)33
Grade Index Scale for • Developed in Sweden as a malocclusion index for treatment need
Assessment of Treatment
Need (GISATN)
-Salonen, Mohlin et al(1992)34
5-Year-Olds’ Index • Frequently used index for cleft lip and palate cases in deciduous dentition
• Applied reliably to photographs of models36 and to clinical photographs.37
- Atack et al (1997)35 • Predicted long term outcome is divided into five following groups:
1. Excellent: Positive overjet with average inclined/retroclined incisors, no crossbite/
openbite, good maxillary shape and palatal anatomy
2. Good: Positive overjet with average inclined/ proclined incisors, unilateral crossbite
or crossbite tendency, open bite tendency around cleft site
3. Fair: Edge-to-edge bite with average inclined or proclined incisors; or reverse overjet
with retroclined incisors, unilateral crossbite, +/- open bite tendency at cleft site
4. Poor: Reverse overjet with average inclined or proclined incisors, unilateral crossbite,
bilateral crossbite, open bite around cleft site
5. Very poor: Reverse overjet with proclined incisors, bilateral crossbite, poor maxillary
arch form and palatal vault anatomy
Index Description
Handicapping Labiolingual • Measurement include cleft palate, traumatic deviations (all or none), overjet, overbite,
Deviation Index (HLDI) mandibular protrusion, anterior openbite and labio-lingual spread
• The Maryland version of HLD; the HLD (Md) index38 modified the HLD’s original scoring
- Draker (1960)17 formula for overjet and overbite.
• The modified HLD (CalMod) index included deep impinging bites and crossbites of
individual anterior tooth with tissue destruction (Parker 1998)39
Malocclusion Severity • Seven weighted and defined measurements are: Overjet, overbite, anterior open
Estimate bite, congenitally missing maxillary incisors, molar relationship, posterior crossbite, tooth
displacement (actual and potential).
- Grainger (1960-61)40 • Six malocclusion syndromes are defined as follows:
1. Positive overjet and anterior openbite
2. Positive overjet, positive overbite, distal molar relationship and posterior crossbite with
maxillary teeth buccal to mandibular teeth
3. Negative overjet, mesial molar relationship and posterior crossbite with maxillary
teeth lingual to mandibular teeth
4. Congenitally missing maxillary incisors
5. Tooth displacement
6. Potential tooth displacement
Occlusal Feature Index (OFI) • Measures four occlusal features: lower anterior crowding, cuspal interdigitation, vertical
overbite and horizontal overjet.
- Poulton & Aaronson (1961)13 • Scoring done according following criteria:
Slight: No need for orthodontic treatment
Mild: Some variation from ideal occlusion but not sufficient to need treatment
Moderate: Orthodontic treatment indicated and would be beneficial
Severe: Treatment essential
Occlusal Index (OI) • Valid tool for measuring occlusion and malocclusion for epidemiological purpose.
• Different scoring scheme for deciduous, mixed and permanent dentition.
- Summers, Arbor (1966, • Nine weighted and defined measurements are: Molar relation, overbite, overjet, posterior
1971)14 crossbite, posterior openbite, tooth, displacement, midline relation, maxillary median
diastema, congenitally missing maxillary incisors
• Seven malocclusion syndromes are:
1. Overjet and openbite
2. Distal molar relation, overbite, overbite, posterior crossbite, midline diastema and
midline deviation
3. Congenitally missing maxillary incisors
4. Tooth displacement
5. Posterior open bite
6. Mesial molar relation, overjet, overbite, posterior crossbite, midline diastema and
midline deviation
7. Mesial molar relation, mixed dentition analysis & tooth displacement
Treatment Priority Index (TPI) • Eleven weighted and defined measurements are: upper anterior segment overjet,
lower anterior segment overjet, overbite of upper anterior over lower anterior, anterior
- Grainger (1967)41 openbite, congenital absence of incisors, distal molar relation, mesial molar relation,
posterior crossbite (buccal), posterior crossbite (lingual), tooth displacement, gross
anomalies
• Seven malocclusion syndromes are: Maxillary expansion syndrome, overbite,
retrognathism, openbite, prognathism, maxillary collapse syndrome, congenitally missing
incisors
Risk of Malocclusion • Tool to assess treatment need and validated instrument to evaluate the malocclusion risk
Assessment Index (ROMA in children with mixed dentition
Index) • Used to individuate not only orthodontic treatment need for children in growing age but
also intervention time and treatment costs in the strength of severity of score.
- Russo, Grippaudo (1998)49 • Identifies 5 grades considering negative effects of malocclusion on both dento-skeletal
apparatus and on psycho-social wellbeing.
Index of Complexity, • Considered highly valid and reliable method
Outcome & Need (ICON) • Developed by a joint effort of 97 orthodontists across 9 countries
• Occlusal trait scores include:
- Daniels & Richmond (2000)22 1. Upper and lower segment alignment
2. Anterior vertical relationship, centerline, impacted teeth, upper and lower buccal
segment alignment, buccal segment AP relationship, buccal segment vertical
relationship, crossbite, missing teeth
3. Esthetic assessment based on IOTN esthetic component, overjet, reverse overjet,
upper and lower incisor inclination relative to occlusal plane, upper arch crowding/
spacing, lip competency
American Board of • Developed as an index to represent the objective evaluation of difficulty of the case
Orthodontics (ABO)/ presented for phase III ABO examination.
Discrepancy Index • Called as discrepancy index (DI)
• Evaluates case complexity based on criteria of case difficulty by evaluating dental
- Cangialosi et al models and cephalometric parameters.
(2004, 2011-12)50,51 • Determinants are overjet, overbite, openbite, crowding, occlusion, lingual/buccal
posterior crossbite, cephalometrics.
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