IOTN
IOTN
IOTN
27/2000/149162
(ENG)
STEPHEN RICHMOND B. D. S ., F. D. S ., R . C . S .
M . SC . D., PH . D.
Department of Dental Health and Development, University Dental Hospital NHS Trust, Heath Park, Cardiff CF4 4XY, U.K.
Abstract. This paper is based on the winning submission for the 1998 Chapman prize awarded by the British Orthodontic
Society for an essay on a subject promoting the interests of orthodontics. The aim of the investigation is to develop a single
index for assessing treatment inputs and outcomes. An international panel of 97 orthodontists gave subjective judgements
on the need for treatment, treatment complexity, treatment improvement, and acceptability on a diverse sample of 240
initial and 98 treated study models. The occlusal traits in the study models were scored according to a defined numerical
protocol. Five highly predictive occlusal traits were identified (IOTN Aesthetic Component, crossbite, upper arch crowding/
spacing, buccal segment antero-posterior relationships, and anterior vertical relationship) and then used to predict the
panellists decisions using regression analysis. Cut-off values were determined for the dichotomous judgements by plotting
specificity sensitivity and overall accuracy. Twenty percentile ranges were used to determine 5 grades of complexity and
improvement. The index prediction of decisions for treatment need, had specificity 844 per cent, sensitivity 852 per cent,
and overall accuracy 85 per cent. When used to predict treatment outcomes, the new index had specificity 648 per cent,
sensitivity 701 per cent, and overall accuracy 681 per cent. The index could explain 756 per cent of the variance in the
mean casewise complexity score and 635 per cent of the mean casewise improvement score. A new orthodontic index is
proposed to assess treatment need, complexity, and outcome. It is based on international orthodontic opinion.
Index words: Icon, Occlusal Index, Orthodontics.
Introduction
Psycho-social Enhancement
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(through middle ear infection), mastication, and dentofacial appearance. Psychosocial affects are profound with
affected individuals experiencing significant childhood
behaviour problems (Spetz et al., 1993), lower marriage
rates (Ramstadt et al., 1995), and higher suicide rates.
Posterior Crossbite
In conjunction with erosion, a crossbite with an associated
slide to intercuspal position can cause considerable tooth
surface loss (Silness et al., 1993). There is a demonstrable
increase in TMD where the slide on closure to intercuspal
position is 4 mm or greater, or in the presence of unilateral
lingual crossbite (McNamara, 1995).
Increased Overjet (Greater Than 6 mm)
Increased overjet is associated with increased trauma to the
upper incisors (Jarvinen, 1978, 1979; Forsberg and Tedestam,
1993) and especially in the presence of incompetent lips
(OMullane, 1973; Ghose et al., 1980; Burden, 1995). There
has been some reports of accentuated periodontal destruction associated with overjets greater than 8 mm (Horup et
al., 1987; Bjornas et al., 1994). It has also been observed that
oral hygiene may be poorer with increased overjet (Geiger
and Wasserman, 1976), and that periodontal pocketing and
gingivitis is increased (Helm and Petersen, 1989). Numerous
studies have noted negative social stereotyping attributed
to individuals with large overjets (Helm et al., 1985; Cons et
al., 1986; Evans and Shaw, 1987; Kilpelaineen et al., 1993).
Reverse Overjet
Certain speech articulation defects have been noted more
commonly in Finnish dental students with Class III incisor
or molar relationship than with normal occlusion (Laine,
1987, 1992). Mandibular prognathism may be perceived
unfavourably and result in social stigmatization (Sergl et al.,
1992, Cons et al., 1986). Mohlin and Thilander (1984) found
that Class III malocclusion was correlated with symptoms
of temporo-mandibular joint dysfunction (TMD) in males,
and Wisth (1984) found in a retrospective sample that a
treated group of class III patients had fewer TMD symptoms
than an untreated control group.
Impeded Eruption or Impaction of Teeth
Impeded teeth may cause follicular cyst formation and
resorption of adjacent teeth (Ericsson and Kurol, 1987).
Anterior Open Bite
This trait has been associated with TMD (McNamara, 1995),
but has a more obvious effect on the reduced efficiency
of biting in the incisor region. Certain speech sounds are
poorly formed in the presence of anterior open bite
(Kletchak et al., 1976).
Hypodontia
Visible missing anterior teeth are considered to be among
the most unattractive occlusal traits (Cons et al., 1986).
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151
Methods
Results
05914
07
03032
06036
04927
06460
03030
02519
03876
05091
03
05
04
05
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Specificity (%)
Sensitivity (%)
Overall accuracy (%)
Cut-off score
Treatment
need
Treatment
outcome
Combined
need
Combined
outcome
864
852
855
43
641
718
690
31
856
836
841
43
648
701
681
31
F I G . 1 The sensitivity, specificity, and overall accuracy of the index to assess treatment need is shown for all possible cut-off values. A suitable cut-off value makes
the best compromise between specificity and sensitivity. For assessments of treatment need the cut-off value is 43.
F I G . 2 The sensitivity, specificity and overall accuracy of the index to assess treatment outcomes is shown for all possible cut-off values. For assessments of
treatment outcome acceptance the cut-off value is 31.
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153
To assess treatment complexity as a 5-point scale it is probably justifiable to use the cut points for the 20 percentile
intervals, using the ranges given in Table 4 from the pretreatment models.
ICON weighting
7
3
5
4
5
43
31
The use of the index to assess end of treatment acceptability has been described above. This method is sufficient
for making qualitative comparisons, but is not sufficiently
sensitive to grade the degree of occlusal change. Occlusal
improvement is usually assessed by comparing the pretreatment assessment with the post-treatment and calculating either the overall score reduction or a percentage
improvement.
TA B L E 4
Complexity grade
Easy
Mild
Moderate
Difficult
Very difficult
Score range
29
2950
5163
6477
77
F I G . 3 The casewise index score is plotted against the casewise average complexity and shows a good correlation. The mean complexity score for the sample is
indicated by the horizontal line.
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Score range
Greatly improved
Substantially improved
Moderately improved
Minimally improved
Not improved or worse
1
25 to 1
53 to 26
85 to 54
85
F I G . 4 The casewise [pretreatment 4 post-treatment] index scores is plotted against the casewise mean improvement score, and demonstrates a moderate
correlation. The red markers indicate cases in which the post-treatment cases would receive an unacceptable rating, i.e. post-treatment score 31.
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155
Conclusions
A new occlusal index is proposed, which is based on the
average opinion of a large panel of international orthodontic opinions. For the first time the design of the index
has been specifically developed to enable assessments of
treatment need and outcome using one set of occlusal traits,
and for this reason may offer clear advances on the currently
used methods. The practical application of the index has
been kept as simple as possible and it is expected that the
index will prove reliable and easy to apply, to study models
or clinically. The accuracy of the index to reflect professional opinion for a diverse sample of cases was estimated
at 84 per cent for decisions of treatment need and 68 per
cent for treatment outcomes.The method is heavily weighted
by aesthetics.
Acknowledgements
We would like to acknowledge the assistance of our
academic colleagues, Professor Berg (Germany), Professor
Adamidis (Greece), Professor Rehk (Hungary), Professor
Miotti (Italy), Professor Prahl-Andersen (the Netherlands), Professor Stenvik (Norway), Professor Canut
(Spain), and Professor Proffit (USA), who facilitated this
study, and our professional colleagues who took part. We
are grateful for the financial support of the European
Union and The University of Wales College of Medicine,
and Dr Frank Dunstan of University of Wales, Medical
Computing Department for statistical advice.
Appendix
General Assumptions of the Index
1. When the index is used to assess treatment outcomes, it
is assumed that an appropriate level of co-operation
was obtained from the patient.
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FIG. 5
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Dental Aesthetics
1. The dental aesthetic component of the IOTN (Shaw
et al., 1991a) is used.
2. The dentition is compared to the illustrated scale and
a global attractiveness match is obtained without
attempting to closely match the malocclusion to a particular picture on the scale. The scale works best in the
permanent dentition.
3. The scale is graded from 1 for the most attractive to 10
the least attractive dental arrangement. Once this score
is obtained it is multiplied by the weighting of 7.
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Crossbite
157
Aesthetic
Upper arch crowding
Upper spacing
Crossbite
110 As judged
using IOTN AC
Score only the highest
trait either spacing or
crowding
Incisor overbite
Transverse relationship
of cusp to cusp or worse
Score only the highest
trait either open bite or
overbite
Lower incisor coverage
Buccal segment
anteroposterior
Less than 2 mm
21 to 5 mm
51 to 9 mm
91 to 13 mm
Up to 2 mm
No crossbite
519 mm
>9 mm
Complete bite
215 mm
Crossbite
present
Less than 1 mm
112 mm
214 mm
Up to tooth
coverage
up to full
covered
Cusp to cusp
relationship
Fully covered
131 to 17 mm
> 17 mm or
impacted teeth
>4 mm
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Once all of the raw scores have been obtained and multiplied by their respective weights, they are added together to
FIG. 6
This case shows missing upper lateral incisors and an impacted upper right canine. See Table 7 for index scoring.
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FIG. 7
159
The treatment has delivered a well aligned occlusion with satisfactory buccal segments. See text for index scoring.
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Pretreatment
score
Post-treatment
score
Weighting
Aesthetic Component
Upper arch crowding
Crossbite
Overbite
Buccal antero-posterior
relationship
Weighted score
Treatment?
Complexity
Improvement
5
5
0
0
2
0
0
1
7
5
5
4
4
72
Yes
Difficult
N/A
Outcome
N/A
1
21
N/A
N/A
Substantially
improved
Acceptable
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