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Adv Clin Exp Med 2016, 25, 6, 1303–1312 © Copyright by Wroclaw Medical University
DOI: 10.17219/acem/62828 ISSN 1899–5276
A – research concept and design; B – collection and/or assembly of data; C – data analysis and interpretation;
D – writing the article; E – critical revision of the article; F – final approval of article
Abstract
Background. Orthodontic classifications make it possible to give an accurate diagnosis but do not indicate an
objective orthodontic treatment need. In order to evaluate the need for treatment, it is necessary to use such indi-
cators as the IOTN.
Objectives. The aim of the study was to find (i) relationships between individual diagnosis and objective recom-
mendations for treatment and (ii) an answer to the question whether and which occlusal anomalies play an impor-
tant role in the objectification of treatment needs.
Material and Methods. Two hundred three 18-year-old adolescents (104 girls, 99 boys) were examined. In order
to recognize occlusal anomalies, the classifications proposed by Orlik-Grzybowska and Ackerman-Proffit were
used. The occlusal anomalies were divided into three categories: belonging to both classifications, typical of Orlik-
Grzybowska classification and typical of Ackerman-Proffit classification. In order to determine the objective need
for orthodontic treatment, the Dental Health Component (DHC) of the IOTN was used.
Results. The occurrence of the following malocclusions covered by both classifications, namely abnormal overjet,
crossbite and Angle’s class, had a statistically significant (p < 0.05) impact on an increase of treatment needs in
the subjects (DHC > 3). As for the classification by Orlik-Grzybowska, dental malpositions and canine class sig-
nificantly affected the need for orthodontic treatment, while in the case of the Ackerman-Proffit scheme, it was
asymmetry and crowding. There was no statistically significant correlation between past orthodontic treatment and
current orthodontic treatment need.
Conclusions. IOTN may be affected by a greater number of occlusal anomalies than it was assumed. Orthodontic
treatment received in the past slightly reduces the need for treatment in 18-year-olds (Adv Clin Exp Med 2016,
25, 6, 1303–1312).
Key words: statistics, orthodontics, malocclusion, Index of Orthodontic Treatment Need.
Diagnosis is one of the key prerequisites for the tion of malocclusions, taking the three-dimension-
proper planning and giving of orthodontic treat- ality of occlusion, function and aesthetics into con-
ment. Edward H. Angle, who developed the first clas- sideration. The most frequently used and globally
sification of malocclusions [1], emphasized the im- recognized division of malocclusions was proposed
portance of correct diagnosis as early as at the turn of in the 1960s by Ackerman and Proffit [2]. In Poland,
the 19th to the 20th century. Based on mesiodistal re- however, the classification proposed by Orlik-Grzy-
lationships between permanent molars, Angle’s clas- bowska [3] has been very popular for decades, both
sification, although used to this day, turned out to be in the educational process and with professionals. Its
imperfect and inaccurate. As a consequence, along main advantages include a comprehensive approach
with the development of orthodontics, researchers to the process of diagnosis and high clarity. Maloc-
have proposed more detailed types of systematiza- clusion divisions are required to define and system-
1304 A. Kozanecka et al.
atize diagnostics, and as such, the more detailed the from the principal of the corresponding school fa-
division, the more useful it is. On the other hand, cility and upon confirmation that a certified school
the classifications of occlusal anomalies used in or- nurse is assigned to such facility. Individual class-
thodontics come down to a qualitative assessment es were randomly selected. The nurse was respon-
and do not allow orthodontists to measurably evalu- sible for preparing office and dental tools (mirrors)
ate the need for orthodontic treatment based on the and complemented the medical records under the
diagnosis. In order to obtain objective information supervision of the orthodontist. All subjects gave
about such needs or the effectiveness of treatment, it their permission to be a part of the study, and were
is necessary to use an indicator such as the Index of informed about the aim and method of the study
Orthodontic Treatment Need (IOTN), Peer Assess- as well as about the freedom of participation in the
ment Rating (PAR) and Index of Complexity Out- project. The individuals who were being treated
come and Need (ICON) [4–6]. To evaluate the need orthodontically at the time of the study were exclud-
for orthodontic treatment, the IOTN is particularly ed from the project (Fig. 1), which was approved
useful; the index, based on the severity of individu- by the Bioethics Committee of the Wroclaw Med-
al occlusal anomalies, allows the patients to be clas- ical University (opinion number KB – 505/2008).
sified into one of five groups: no need for treatment, The profile of the study group is shown in Table 1.
slight need for treatment, moderate/borderline need In each case, the study was conducted by the
for treatment, need for treatment, and definite need same doctor, who was trained in the use of the
for orthodontic treatment. The IOTN is not based Dental Health Component of the IOTN. Informa-
on any orthodontic classification and does not con- tion about orthodontic treatment the subjects had
sider the diagnosis. The index value is determined received in the past was collected on the basis of
by the presence and severity of anomalies belong- the patient’s medical history (anamnesis).
ing to one of five categories: missing teeth, overjet, In order to recognize occlusal anomalies, two
crossbite, displacement of anatomical contact points classifications were used, namely: [1] by Orlik-
and overbite [7]. Grzybowska and [2] the Ackerman-Proffit scheme.
In view of the foregoing, it seems justified to
make an attempt to find both (i) relationships be-
tween individual diagnosis and objective recom- Initially eligible:
mendation for treatment and (ii) an answer to the 18-year-old adolescents
question whether and which malocclusions (identi- from randomly selected
Polish secondary schools
fied on the basis of a given classification) play an im-
n = 238
portant role in the objectification of treatment needs.
The aim of the study was to (i) determine which
of the classifications of malocclusions, that is by Orlik- Rejected: active orthodontic
Grzybowska or Ackerman-Proffit, play a more sig- treatment
nificant role in the objectification of treatment needs, n = 27
and (ii) evaluate the possible impact of orthodontic
treatment received in the past on the incidence of oc-
Rejected: refused
clusal anomalies and current need for treatment. participation
n=8
According to the classification by Orlik-Grzy- overjet, anterior and lateral open bite, anterior and
bowska, the following malocclusions were diag- complete deep overbite;
nosed: b) malocclusions typical of classification by
a) transverse malocclusions: Orlik-Grzybowska such as: canine classes, dental
− crossbites: partial anterior crossbite right/ malpositions, functional and morphological man-
left, partial unilateral crossbite right/left, partial dibular lateral displacement, partial and complete
bilateral crossbite, complete crossbite, functional distoclusion, pseudo-distoclusion, functional and
mandibular lateral displacement, morphological morphological retrusive occlusion, partial and to-
mandibular lateral displacement; tal mesioclusion, pseudo-mesioclusion, functional
− scissor bite: unilateral lingual (right/left), and morphological protrusive occlusion;
bilateral scissor bite; c) malocclusions typical of Ackerman-Prof-
b) anterior-posterior malocclusions: fit classification such as: symmetry of the upper
− distoclusions (class II malocclusions): par- and lower arch, spacing (in mm) and crowding (in
tial distoclusion (molars in class I, canines in class mm).
II), complete distoclusion (molars in class II), In order to determine the objective need for
pseudo distoclusion (prognathic position of max- orthodontic treatment, the Dental Health Com-
illa), functional retrusive occlusion, morphological ponent of the Index of Orthodontic Treatment
retrusive occlusion (retrogenia); Need was used. In accordance with the recom-
− mesioclusions (class III malocclusions): par- mendations of the index authors, individual ele-
tial mesioclusion (molars in class I, canines in class ments of occlusion were evaluated, including in
III), complete mesioclusion (molars in class III), particular: the presence of retained teeth or lack of
pseudo mesioclusion (maxillary deficiency), func- buds, the size of overjet, crossbite, crowding sever-
tional protrusive occlusion, morphological protru- ity (displacement of anatomical points of contact
sive occlusion (mandibular prognathism); measured in millimeters) and size of overbite [7].
c) vertical malocclusions: Linear measurements of the size of overjet, over-
− open bites: partial anterior open bite, partial bite, crowding and spacing were taken with a dig-
unilateral open bite right/left, partial bilateral open ital caliper to an accuracy of 0.1 mm. The values
bite, complete open bite (skeletal); of the Dental Health Component and the corre-
− deep overbites: partial deep overbite, com- sponding occlusion characteristics are shown in
plete deep overbite (skeletal); Table 2. DHC value = 1 means no need for orth-
d) teeth malpositions: mesiorotation, disto- odontic treatment, DHC = 2: slight need for treat-
rotation, mesioinclination, distoinclination, pala- ment, DHC = 3: moderate/borderline need for
totrusion, linguotrusion, vestibulotrusion [3]. treatment, DHC = 4: a need for orthodontic treat-
According to the Ackerman-Proffit classifica- ment, DHC = 5: definite need for orthodontic
tion, the following malocclusions were diagnosed: treatment [7].
− symmetry of the upper and lower arch, spac- Statistical analysis was performed using the
ing and crowding (and their sum for a given arch; SPSS 16.0 (2008) and STATISTICA v. 10.0 (Stat-
the size of crowding was determined as the differ- Soft Inc., 2011) software packages. Descriptive sta-
ence between the sum of the tooth widths and the tistical analysis was performed. The distribution of
alveolar ridge length); qualitative parameters was determined using fre-
− tooth relationships to the transverse plane quency tables. For quantitative traits, the measures
(the presence of unilateral and bilateral crossbite); of location, variability, asymmetry and concentra-
− anterior-posterior tooth relationships (eval- tion were defined. The adherence of quantitative
uation of Angle’s classes, overjet, diagnosis of an- variables to the normal distribution was evaluat-
terior-posterior malocclusions); ed using the Shapiro-Wilk test. The relationships
− tooth relationships in the vertical plane (an- between variables were analyzed using the chi-
terior and lateral open bite diagnostics and ante- square test for independence. The Kruskal-Wal-
rior deep overbite diagnostics, evaluation of the lis and Dunn multiple comparison tests were used
overbite size) [2]. to identify intergroup differences. The significance
Due to the lack of the first permanent molars, level α = 0.05 was assumed. The results were con-
defining the Angle’s class was impossible in the sidered statistically significant when the calculated
cases of 9 patients on the right side and in 12 pa- probability p-value satisfied the inequality p < 0.05.
tients on the left side. In the final stage of data analysis, an attempt was
The occlusal anomalies evaluated in this way made to build a statistical model that would illus-
were divided into: trate the dependence of the IOTN DHC parame-
a) malocclusions belonging to both classifica- ter on individual malocclusions. To this end, de-
tions such as: crossbite, Angle’s classes, overbite, pendent variable regression techniques were used.
1306 A. Kozanecka et al.
Table 2. Dental Health Component of the Index of Orthodontic Treatment Need (Richmond 2008)
Malocclusion Frequency
Partial anterior crossbite right/left 9 (4.4%)/4 (2%)
Partial posterior crossbite right/left 17 (8.3%)/15 (7.3%)
Partial bilateral crossbite 6 (3%)
Complete crossbite right/left 3 (1.5%)/0 (2%)
Lateral functional shift of the mandible 1 (0.5%)/1 (0.5%)
Lateral morphological shift of the mandible 0/0
Unilateral scissor bite right/left 2 (1%)/8 (3.9%)
Bilateral scissor bite 3 (1.5%)
Partial distoclusion 7 (3.4%)
Complete distoclusion 41 (20.2%)
Pseudo distoclusion 0
Functional retrusive occlusion 14 (6.9%)
Morphological retrusive occlusion 3 (1.5%)
Partial mesioclusion 2 (1%)
Total mesioclusion 8 (3.9%)
Spurious mesioclusion 0
Functional protrusive occlusion 1 (0.5%)
Morphological protrusive occlusion 6 (3.0%)
Canine class I right/left side 140 (69%)/139 (68.5%)
Canine class II right/left side 53 (26.1%)/50 (24.6%)
Canine class III right/left side 10 (4.9%)/14 (6.9%)
Partial anterior open bite 8 (3.9%)
Partial posterior open bite right/left 4 (2%)/3 (1.5%)
Bilateral open bite 1 (0.5%)
Complete open bite 1 (0.5%)
Partial deep overbite 33 (16.3%)
Total deep overbite 1 (0.5%)
ment for malocclusions in the past, an objectively and such dental malpositions as distorotation, pal-
significant need for further treatment was found atal position and canine class on the right side in
in the case of the prevalence of abnormal overjet, the subjects orthodontically treated in the past.
crossbite, and right-sided Angle’s class. The parameters taken into account in the
Variables occurring only in the classification Ackerman-Proffit classification also significant-
proposed by Orlik-Grzybowska also significantly ly (p < 0.05) influenced the need for treatment.
(p < 0.05) determined the objective need for orth- These parameters included: asymmetry in the up-
odontic treatment (DHC > 3). They included: dis- per or lower arch and crowding in the upper or
toclusion, retrusive occlusion, canine class and all lower arch in untreated subjects and asymmetry in
evaluated dental malpositions (mesiorotation, dis- the upper or lower arch and crowding in the up-
torotation, mesioinclination, distoinclination, pal- per arch in patients who had undergone orthodon-
atotrusion, linguotrusion, vestibulotrusion, palatal tic treatment.
position, lingual position and vestibular position) The regression function of the dependent vari-
in the subjects with no orthodontic medical record able was used to make an attempt to build a math-
1308 A. Kozanecka et al.
Table 4. Tooth malposition frequency according to Orlik- Table 7. Dental Health Component of the Index of
Grzybowska Orthodontic Treatment Need in the group of subjects
“Common” – common features found in both classifications; “O-G” – classification by Orlik-Grzybowska; “A&P”
– Ackerman-Proffit classification.
Table 9. Relationship between particular malocclusions and the Dental Health Component (DHC) in subjects who had
1310
received orthodontic treatment in the past (n = 60)
A. Kozanecka et al.
“Common” – common features found in both classifications; “O-G” – classification by Orlik-Grzybowska; “A&P”
– Ackerman-Proffit classification.
Diagnosis vs. Orthodontic Treatment Need 1311
same age group, the prevalence of malocclusion the need for treatment was observed in 21.4% of
among high school students was very high: its per- all the subjects. This percentage is higher than in
centage was 70% [12]. Finnish studies (15% of the subjects required treat-
As mentioned above, objective indicators such ment), comparable to British (21%) and French
as the IOTN are frequently used in epidemio- (21%) findings and lower than results obtained by
logical studies. Their use guarantees repeatabil- Italian researchers (27.3%) [16–19].
ity of results, and allows researchers to compare The result of the analysis of the relationship
their results to those obtained by others [13–15]. between the DHC and the diagnostic elements
The crucial point, however, is, what is the relation- may support the hypothesis that early orthodontic
ship between subjective (i.e. a diagnosis determin- treatment resulted in a reduction of the variety of
ing the treatment plan) and objective evaluation indications to therapy in the future. While in the
(i.e. the actual need for orthodontic treatment)? case of untreated subjects, there were many factors
The study showed that, apart from the previous- that determined the need for orthodontic treat-
ly-defined anomalies, there are others that affect ment (cross bite, Angle’s Class on the right side,
the value of the Dental Health Component of the abnormal overjet, open bite, canine class, dental
IOTN, covered by the classification of malocclu- malpositions, distoclusions, asymmetry of dental
sion proposed by Orlik-Grzybowska and the Ack- arches and crowding), in the case of treated sub-
erman-Proffit scheme. The factors of particular jects, such factors were considerably less numer-
importance include: the size of overjet, which is ous. The value of the DHC among 18-year-olds
the symptom of most common malocclusions, dis- who had undergone orthodontic treatment was af-
toclusions, crossbite and crowding. However, the fected by: crossbite, overjet, some dental malposi-
objective need for orthodontic treatment was al- tions, canine class and Angle’s Class on the right
so found in the case of open bite, dental malposi- side, asymmetry of arches and crowding in the up-
tions, distoclusions or asymmetry of dental arch- per arch.
es. The said mathematical model is an attempt to There is a need to revise the assumptions of
connect the diagnosis with the need for treatment. the authors’ IOTN index – it seems that this ratio
The model explains only 30% of the DHC varia- may be affected by greater number of malocclu-
tion and requires the use of elements from both sions than it was assumed (e.g. crossbite, open bite,
classifications (that is by Orlik-Grzybowska and dental malpositions, distoclusions, and asymmetry
the Ackerman-Proffit scheme). It requires a verifi- of dental arches and crowding).
cation in the future on a larger examined group if The results presented herein have shown that
it can be useful in practice. orthodontic treatment received in the past slightly
When discussing the results, attention should reduces the need for treatment in 18-year-olds and
be paid to the Dental Health Component value in revealed that both orthodontic prevention and in-
the context of orthodontic treatment possibly re- creased effectiveness of early treatment are gain-
ceived in the past. Interestingly, the need for orth- ing in importance. Therefore, it needs to be em-
odontic treatment was reported in 18% of treated phasized that interceptive orthodontic treatment
and in 22.9% of untreated 18-year-olds. This can as well as efficient elimination of already existing
be explained by the fact that removable orthodon- malocclusions in children may factually reduce
tic devices – used to treat mild cases – were the health care spending on adult patients.
main treatment method. Subsequent changes re- Further studies in larger groups can signifi-
lated to the patient’s growth or possibly lack of co- cantly contribute to a better planning of orthodon-
operation on his/her part, may have contributed to tic treatment and may help to improve orthodon-
the treatment ineffectiveness as well. In this study, tic care at the state level.
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Received: 26.08.2015
Revised: 12.03.2016
Accepted: 25.04.2016