Review Article

A Review of Orthodontic Indices

Dr Alka Gupta,1 Dr Rabindra Man Shrestha2
PG Resident, 2Associate Professor
1

Dept of Orthodontics, Kantipur Dental College, Kathmandu, Nepal

Correspondence: Dr Rabindra Man Shrestha; email: [email protected]

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.

INTRODUCTION ultimate point (disease in its terminal stage).

2. The index should be equally sensitive throughout the
British Society of Orthodontics in 1922 defined orthodontic
scale.
specialty as, ‘Orthodontics includes the study of the growth
and development of the jaws and face particularly, and 3. The score should correspond closely with the clinical
the body generally as influencing the position of the teeth; importance of the disease stage it represents.
the study of action and reaction of internal and external 4. Index value should be amendable to statistical
influences on the development and the prevention and analysis.
correction of arrested and perverted development’. 1 5. The index must be reproducible.

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.

44 Orthodontic Journal of Nepal, Vol. 4, No. 2, December 2014

 Gupta A, Shrestha RM : A Review of Orthodontic Indices

1. Diagnostic indices 4. Orthodontic Treatment Outcome indices

• Angle Classification System (1899)8 • Peer Assessment Rating Index (PAR) (Richmond et
• Incisal categories of Ballard & Wayman (1964) 9 al, 1992)23
• Five-point system of Ackerman & Proffit (1969)10 • Index of Complexity, Outcome & Need (ICON)
(2000)22
2. Epidemiologic indices
5. Orthodontic Treatment Complexity Indices
• Index of Tooth Position (Massler & Frankel, 1951)11
• Index of Orthodontic Treatment Complexity (IOTC)
• Malalignment Index (Van Kirk & Pennel, 1959)12
(Liewellyn et al, 2007)24
• Occlusal Feature Index (Poulton & Aaronson,
• Index of Complexity, Outcome & Need (ICON)
1961)13
(2000)22
• The Bjork Method (1964)6
The method for recording malocclusion can be classified
• Summers’ Occlusal Index (1971)14
into qualitative and quantitative methods.25 Qualitative
• The FDI method (Baume et al, 1973)15 method describes the occlusal features and provides
• Little’s Irregularity Index (1975)16 descriptive classification of the dentition, however does
3. Orthodontic treatment need indices not provide any information of the treatment need
• Handicapping Labio-lingual Deviation index (HLD) and outcome. Malocclusion symptoms are recorded
(Draker, 1960, 1967)17 in all or none manner as the studies on epidemiology of
malocclusion do not define the method of measuring the
• Swedish Medical Board Index (SMHB 1966; Linder
variables.26
Aronson, 1974, 1976)18,19
Quantitative methods quantify the complexity and
• Dental Aesthetic Index (DAI) (Cons et al, 1986)20
severity of the problem rated in a scale or proportion.
• Index of Orthodontic treatment Need (IOTN)
They are used to prioritize the need for treatment. Their
(Brook & Shaw, 1989)21
use minimizes the subjectivity related to the diagnosis,
• Index of Complexity, Outcome & Need (ICON) outcome and complexity assessment of orthodontic
(Daniel & Richmond, 2000)22 treatment.

Qualitative methods of measuring malocclusion

Index Description

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.

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 Gupta A, Shrestha RM : A Review of Orthodontic Indices

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

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 Gupta A, Shrestha RM : A Review of Orthodontic Indices

Quantitative methods of measuring malocclusion

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

Swedish Medical Board • Developed by Swedish Medical Health Board

Index (SMBI) • Treatment need is represented by 4 categories (Grade 1 to 4);
• Later Linder-Aronson revised the index by adding fifth category of Grade zero.
- SMHB (1966); -Linder- • Categorized as Grade 4-0; very urgent need, urgent need, moderate need, little need
Aronson (1974, 1976)18,19 and no need.
• Features like esthetically and/or functionally handicapping anomalies such as cleft lip
and palate, aplasia, occlusion, deep bite, open bite, crossbite, scissors bite, overjet,
crowding, spacing, rotation, retained teeth are considered.

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

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 Gupta A, Shrestha RM : A Review of Orthodontic Indices

Handicapping Malocclusion • Weighted measurements consist of following three parts:

Assessment Index (HMAR) 1. Intra-arch deviation: Missing, crowding, rotations, spacing
2. Inter-arch deviation: Overjet, overbite, crossbite, open bite mesiodistal deviation
- Salzmann (1968)42 3. Six handicapping dentofacial deformities: Facial and oral clefts, lower lip palatal to
maxillary incisors, occlusal interferences, functional jaw limitation, facial asymmetry,
speech impairment
Eismann Index (EI) • Based on Bjork’s method
• Objective method of measuring malocclusion and assessing the efficacy of orthodontic
- Eismann (1974)43 treatment
• Based on numerical evaluation of 15 morphological traits of malocclusion
• Modified by Farcnik et al in Slovenia.44.45
Irregularity Index • Simple, reliable and valid method of measuring linear displacement of the anatomic
contact point
- Little (1975)16 • Used by public health and insurance program to establish the severity of malocclusion
and priority of treatment.
• Five linear displacement of adjacent contact point starting from mesial of right lower
canine to mesial of left lower canine are recorded.
• Model cast is ranked on a scale ranging from 0-10.

Dental Aesthetic Index (DAI) • Developed in USA

• Integrated into International Collaboration Study of Oral Health Outcomes by WHO as an
- Cons et al (1986)20 international index
• Links clinical and aesthetic components mathematically to produce a single score that
combines physical and aesthetic aspects of occlusion, including patient perceptions.
Goslon Yardstick Index • Used in Great Ormond Street, London and Oslo.
• Clinical tool that allows the categorization of dental relationships in late mixed dentition
- Mars et al (1987)46 and early permanent dentition into five discrete categories
Group 1: Excellent- No treatment
Group 2: Good- Simple orthodontic treatment/ no treatment
Group 3: Fair- Complex orthodontic treatment, good result anticipated
Group4: Poor- Limited orthodontic treatment without orthognathic surgery if growth is
favorable
Group 5: Very poor- Orthognathic surgery, categorizes malocclusion in cleft lip &
palate.
Standardized Continuum • Developed in UK
of Aesthetic Need (SCAN • Dental occlusion is matched with overall dental attractiveness against ten-scaled
Index) photographs of Aesthetic Component of IOTN.
• Useful in state-funded hospital services.
- Evans & Shaw (1987)47
Index of Orthodontic • IOTN has two components: Dental health component (DHC) and Aesthetic component
Treatment Need (IOTN) (AC).
• DHC comprise of five grades of treatment need ranging from Grade 1-5; none, little,
- Brook & Shaw (1989)21 moderate, great & very great.
• Features like displacement, overjet, crossbite, openbite, occlusion, hypodontia, defects
of cleft lip and palate, overjet, impeded eruption, supernumerary teeth, retained
deciduous teeth, other pathologic cause
• Aesthetic Component consists of 10-grade standard reference photographs representing
different grades of dental attractiveness.
Peer Assessment Rating • Comprise of 11 following components; upper right segment, upper anterior segment,
(PAR) Index upper left segment, lower right segment, lower anterior segment, lower left segment, right
buccal occlusion, overjet, overbite, centre line & left buccal occlusion.
- Richmond (1992)23
Norwegian Orthodontic • A new approach to the combination of public and private funding of treatment to
Treatment Index (NOTI) determine the level of public health copayment to the patient.
• On morphologic and functional basis, four groups defined are: very great, great, obvious,
- Espeland, Ivarsso, Stenvik little/no need
(1992)48 • Used in total reimbursement for severe malocclusion with cleft lip and palate, and partial
or nil reimbursement for other malocclusions.

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 Gupta A, Shrestha RM : A Review of Orthodontic Indices

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.

Index of Orthodontic • A simple method measuring relatively few traits

Treatment Complexity (IOTC) • Can be used on patients and study casts
• Valid for the assessments of treatment need, complexity and outcome
- Liewellyn et al (2007)24 • Avoids the need to use different indices for different forms of assessment
• Identification of the level of expertise needed to treat a specific case, allocation of
health care resources, appropriate recognition of professionals undertaking complex
care, and provision for better patient information regarding the likely complexity of the
treatment.

DISCUSSION model serves as a patient awareness tool for the patients

and allows three-dimensional analyses. Traditionally, the
The present article reviewed various orthodontic indices
opinion and experience of the orthodontist are used to
available in the literature. Classification of orthodontic
explain the discrepancy of the dental arches. In fact,
indices proposed by Shaw et al7 is the most comprehensive
no single classification is found to be ideal, accurate,
system found. Descriptions on indices and methods of the
valid and reliable for assessing the malocclusion and
assessment of malocclusion mentioned in the present
yet that is simple. There have been many disagreements
article are based on the opinion of respective authors.
among the authors and researchers about various
Initially malocclusions used to be described as per the indices, therefore many newer systems are developed
clinical features on qualitative basis, later there have been to fulfill the shortcomings of the antecedents. Angles
attempts to quantify them in scale and scores. The present classification8 is still the most widely used system in clinical
article also attempts to categorize various orthodontic and epidemiological purposes and IOTN21 is perhaps the
indices into qualitative and quantitative methods. most accepted index for assessing treatment need. ABO
Most of the orthodontic indices use study model for Discrepancy Index50,51 serves as the contemporary tool for
analysis, however direct examination on patients and complexity scores and academic evaluations.
photographs have also been used in other systems. Study OJN

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