OPEN ACCESS Journal of Orthodontics, Vol.

41, 2014, 77–83

An Index of Orthognathic Functional Treatment Need

(IOFTN)
Anthony J. Ireland1, Susan J. Cunningham2, Aviva Petrie3, Martyn T. Cobourne4, Priti Acharya5, Jonathan R.
Sandy1 and Nigel P. Hunt2
1
Child Dental Health, School of Oral and Dental Sciences, University of Bristol, Bristol, UK; 2Orthodontic Department, UCL Eastman Dental
Institute, London, UK; 3UCL Eastman Dental Institute, University of London, London, UK; 4Orthodontic Department, Kings College Dental
Institute, Guys Campus, London, UK; 5Orthodontic Department, Eastman Dental Hospital UCLH Foundation Trust, London, UK

Objective: To design a new index categorizing the functional need for orthognathic treatment. Design: Laboratory-
based study. Setting: Records were obtained from two UK hospital-based orthodontic departments. Participants: A
panel of four consultant orthodontists, experienced in providing orthognathic care, devised a new index of
Orthognathic Functional Treatment Need (IOFTN) with the aid of the membership of the British Orthodontic
Society Consultant Orthodontists Group (COG). Twenty-three consultants and post-CCST level specialists took part
in the study as raters to test the validity and reliability of the new index. Methods: A total of 163 start study models
of patients who had previously undergone orthognathic treatment were assessed by the panel of four consultant
orthodontists using the new index (IOFTN) and the agreed category was set as the ‘gold standard’. Twenty-one
consultants and post-CCST level specialists then scored the models on one occasion and two scored 50 sets of models
twice to determine the test–re-test reliability. Results: Kappa scores for inter-rater agreement with the expert panel
for the major categories (1–5) demonstrated good to very good agreement (kappa: 0.64–0.89) for all raters. The
percentage agreement ranged from 68.1 to 92% in all cases. Intra-rater agreement for the major categories was
moderate to good (kappa: 0.53–0.80). Conclusions: A new index, the IOFTN, has been developed to help in the
prioritization of severe malocclusions not amenable to orthodontic treatment alone. It demonstrates good content
validity and good inter-rater and moderate to good intra-rater reliability. As a result of being an evolution of the
IOTN, the familiar format should make it easy to determine functional treatment need within daily orthognathic
practice.
Key words: Indices, orthognathic, IOTN, IOFTN

Received 2 April 2014; accepted 27 April 2014

Introduction from orthodontic treatment, as well as to monitor the

Globally, the disciplines of medicine and dentistry use quality of treatment outcome. In the prioritization of
indices of health widely and these have been developed treatment provision, we have become familiar with the
for many different purposes. Uses include the classifica- use of the Index of Orthodontic Treatment Need
tion of conditions to aid the understanding of aetiology, (IOTN) (Brook and Shaw, 1989), which has been in
risk, prognosis and treatment outcome (Sharabiani routine use in NHS primary care in England and Wales
et al., 2012). They can also be used to determine since 2006, and somewhat earlier than this in many
prevalence and or incidences within a population, and secondary care settings (Holmes and Wilmott, 1996).
therefore, help in the planning and provision of This index was developed with the aim of prioritizing
treatment at the individual or population levels. In the functional need for treatment through its dental
recent years, their use in the planning of services, health component (DHC) and psychosocial need
particularly within cash-limited, publicly funded health through the aesthetic component (AC). This was not
services such as the UK National Health Service, has the first such index used for this purpose in orthodon-
gained greater acceptance. Our own experience within tics, with indices such the Handicapping Labio-lingual
orthodontics is that indices have been used to prioritize deviations index (Draker, I960), the Treatment Priority
treatment to those most in need and likely to benefit Index (Grainger, 1967), the Handicapping Malocclusion

Address for correspondence: A. J. Ireland, Child Dental Health,

School of Oral and Dental Sciences, University of Bristol, Lower
Maudlin St., Bristol BS1 2LY, UK
Email: [email protected]
# 2014 British Orthodontic Society
MORE OpenChoice articles are open access and distributed under the
terms of the Creative Commons Attribution Non-Commercial License 3.0 DOI 10.1179/1465313314Y.0000000100
 78 Ireland et al. Open Access JO June 2014

Assessment Record (Salzmann, 1968) and the Occlusal the IOTN in the absence of any other occlusal traits, and
Index (Summers, 1971) all having been developed earlier yet this can lead to potential gingival and periodontal
than the IOTN. The IOTN itself is a modification of an problems and might only be amenable to treatment with
index previously developed by the Swedish Dental combined orthodontic and orthognathic treatment.
Health Board (Linder-Aronson, 1974). With these limitations in mind, it was decided to create
In the process of developing an index of health, a a new Index of Orthognathic Functional Treatment
number of factors must be taken into consideration. The Need (IOFTN), using wherever possible the same traits
principal factor is its intended purpose, but ease of use as used in the IOTN DHC, but with modifications and
in daily practice is also important, since it may involve additions to reflect the functional indications of treat-
the collection and interpretation of a large amount of ment need for orthognathic patients. In this way, it was
data from which, a single useful indicator is then hoped to create an index that feels familiar to those
provided (Arvaniti and Panagiotakos, 2008). In addi- using the IOTN, is valid, reliable and quick and easy to
tion, an index should be both valid and reliable. A use. This paper describes the development of this new
number of studies have been carried out to assess the index.
validity and reliability of the IOTN, as well as the time
taken to use the index. Validity is often measured
against expert opinion. In comparison with other Materials and methods
orthodontic occlusal indices, the strengths of the Using the IOTN DHC as a starting point, four
IOTN DHC component are, not only its validity and consultant orthodontists with extensive experience in
reliability, but also that it is quick and easy to use treating orthognathic patients (AJI, SJC, MTC, NPH)
(Cardoso et al., 2011). Moreover, the grading also devised a draft IOFTN based on a five-point scale
appears to be unaffected by age, at least within the ranging from Very Great Need for Treatment (5)
relatively narrow age range of the adolescent patient through to No Need for treatment (1). The draft index
(Cooper et al., 2000). As a result, it is not only widely was then presented at the British Orthodontic Society
used in orthodontic research (Bellot-Arcı́s et al., 2012), Consultant Orthodontists Group (COG) Symposium in
but is also highly rated by those involved in planning Bristol during March 2013, following which it was
orthodontic service provision within the UK (de formally circulated to all 280 members of the COG
Oliveira, 2003). for written comment. Forty-six members replied with
The IOTN DHC is a straightforward five-point scale, written comments and these were then reconsidered at a
with the greatest need for treatment classified as being further meeting of the panel of experts. Modifications
group 5 and little or no need for treatment classified as were made to the wording of the index to reflect the
group 1. Within each group, there are well defined comments and at this point the index was considered to
descriptors of the features of the malocclusion deemed have face validity.
as indicators of orthodontic need (such as overjet, The panel of four experts then worked in pairs to score
impacted teeth and missing teeth). The reason the index 163 sets of start study models using the new index. The
is quick and easy to apply is that the malocclusion is sample of models represented various malocclusions
scored simply on the worst feature. In order to identify that had previously been treated using an orthognathic
this feature in a systematic manner it is suggested the approach. The scores were then compared and, wher-
assessor uses the acronym MOCDO (Missing teeth, ever there was disagreement, the panel discussed them
Overjet, Crossbites, Displacement of contact points, and came to a consensus score for each of the 163 sets of
Overbite) (Richmond et al., 1994). models. At this point, the index (Figure 1) was
Currently within the NHS, orthodontic treatment is considered to have content validity, as it was felt that
limited to IOTN DHC groups 4 and 5, and group 3 all of the possible facets of the construct of whether or
where the AC is grade 6 or above. Although widely not an orthognathic treatment approach was appro-
used, there are some limitations of the IOTN. In the case priate for functional reasons, had been considered.
of the AC of the index, it comprises only class I and class Twenty-one specialist orthodontists with experience of
II division 1 incisor relationships and there are no class orthognathic treatment, all consultant orthodontists and
II division 2 or class III incisor relationships. In the case senior FTTAs were then asked to score the 163 sets of
of the DHC, some of the functional indications for models using the new index, in order to test agreement
orthognathic treatment are not included, or might be with the expert panel scores. The scores were then
classified differently if the malocclusion were not analysed using Cohen’s kappa for inter-operator agree-
treatable with orthodontics alone. For example, exces- ment with the expert panel scores when assigning the
sive upper labial segment show at rest is not included in patient to one of the five major categories. It also looked
 JO June 2014 Open Access Index of Orthognathic Functional Treatment Need 79

Figure 1 The Index of Orthognathic Functional Treatment Need (IOFTN)

 80 Ireland et al. Open Access JO June 2014

at assignment within the major categories to the considered good. When the agreement for the subcate-
individual sub-categories (for example, having decided gories within the major categories was compared with
a patient was in category 5, what was the agreement for the expert panel score, it was also good to very good for
allocation to the subcategories within the major all raters (Table 3), 2–5. There were too few models in
category). In addition, the percentage agreement with category 1 for statistical testing as few patients in this
all of the categories scored by the experts was also category will have undergone orthognathic treatment.
determined for each of the 21 assessors. The weighted kappa scores for intra-operator agree-
In order to determine the intra-operator agreement, ment were 0.53 for operator 1 and 0.80 for operator 2,
two consultants scored 50 sets of study models on two showing moderate to good agreement over time for each
separate occasions 1 week apart. Agreement was again rater. The percentage agreement for all categories and
tested using Cohen’s kappa for the main groups. subcategories was 68 and 76%, respectively.

Results Discussion
The results were analysed using SPSS (IBM SPSS In recent years, there has been a drive to reduce costs
Statistics 22.0; IBM Corp., Chicago, IL, USA) and within the UK NHS, not only to reduce overall
Stata Version 13 (STATA Corp., College Station, TX, spending, but also to divert money and resources from
USA). Table 1 is the summary table of the 163 study what are deemed ‘low priority’ treatments, to those
models, illustrating the number of models in each of the deemed to be of higher value and where the evidence to
IOFTN categories. The kappa scores for inter-operator support their use is said to be greater. As far back as
agreement with the expert panel scores for the major 2006, primary care trusts in England responsible for
categories are illustrated in Table 2, and this shows NHS funding within their areas began compiling lists of
good to very good agreement for all raters. The what they considered low priority treatments. One such
percentage agreement of the 21 assessors with the expert list, the Croydon List has received much attention and
panel scores for all categories is illustrated in Figure 2 comprised 34 treatments. Other PCTs compiled much
and ranged from 68.1 to 92%. The per cent agreement longer lists of over 100 procedures and this prompted
was over 80 for 16 of the 21 assessors, which can also be the Audit Commission in 2011 to suggest that their
implementation in commissioning health could lead to
Table 1 Numbers of models in each of the categories of annual savings to the NHS of £500 million (Audit
the IOFTN
Table 2 Kappa scores illustrating strength of agreement
Category 5 Number of models between the major category scores of each of the 21
assessors with the expert panel major category scores
5.1 9
5.2 9
(,0.25poor; 0.21–0.405fair; 0.41–0.605moderate; 0.61–
5.3 8 0.805good; 0.81–1.005very good agreement)
5.4 10
5.5 2 Assessor number Kappa score
5.6 0
5.7 5 1 0.85
Category 4 2 0.88
4.2 12 3 0.66
4.3 14 4 0.75
4.4 2 5 0.73
4.8 10 6 0.64
4.9 8 7 0.78
4.10 10 8 0.81
Category 3 9 0.83
3.3 13 10 0.81
3.4 7 11 0.80
3.9 0 12 0.83
3.10 9 13 0.87
Category 2 14 0.80
2.8 8 15 0.88
2.9 18 16 0.64
2.11 9 17 0.84
Category 1 18 0.89
1.12 0 19 0.76
1.13 0 20 0.81
1.14 1 21 0.74
 JO June 2014 Open Access Index of Orthognathic Functional Treatment Need 81

Figure 2 Histogram illustrating the percentage agreement of each of the 21 assessors with the expert panel
scores for all of the 23 categories within the IOFTN

Table 3 Kappa scores illustrating strength of agreement

Commission, 2011). Although the audit commission
for the subcategories within each major category score
found some commonality in the lists, there was not for each of the 21 assessors with the expert panel scores
complete uniformity. What could be considered low (,0.25poor; 0.21–0.405fair; 0.41–0.605moderate; 0.61–
priority in one area might automatically receive funding 0.805good; 0.81–1.005very good agreement)
in another, leading to the potential for a ‘postcode
lottery’ of access to healthcare. In 2012, the South Assessor IOFTN 5 IOFTN 4 IOFTN 3 IOFTN 2
Central PCTs, in consultation with Solutions for Public 1 0.91 0.97 0.94 1.00
Health, investigated the evidence to support the routine 2 0.91 0.98 0.93 1.00
funding of orthognathic treatment for reasons of 3 0.72 0.96 0.91 1.00
4 0.94 1.00 0.93 1.00
function, sleep apnoea, speech and temporomandibular 5 0.97 0.97 1.00 1.00
joint dysfunction. Following this investigation, the 6 0.91 0.89 0.82 1.00
southern cluster within the South Centrals area decided 7 0.94 0.94 1.00 1.00
8 0.90 1.00 1.00 0.95
that all orthognathic treatment should be considered to 9 0.97 1.00 1.00 0.95
be of low priority, except for severe sleep apnoea, cleft 10 0.96 0.95 1.00 1.00
lip and palate and following major trauma (HIOW/ 11 0.97 0.87 1.00 1.00
12 0.94 1.00 1.00 1.00
SHIP Priorities Committee April 2008 to March 2012). 13 0.88 0.97 0.88 1.00
The northern cluster also considered it to be low priority 14 1.00 1.00 0.89 1.00
and decided not to fund treatment for speech or 15 0.87 0.97 0.94 1.00
16 0.91 0.87 1.00 1.00
temporomandibular joint dysfunction, but were pre- 17 0.94 0.95 0.93 0.95
pared to continue funding for functional reasons and 18 0.97 1.00 1.00 1.00
sleep apnoea, and provided the patients were categor- 19 0.94 0.97 1.00 1.00
20 1.00 0.89 0.71 1.00
ized as IOTN 4 or 5 (Solutions for Public Health, 2012). 21 0.97 0.91 0.87 0.94
It was at about the same time that the Strategic Health
 82 Ireland et al. Open Access JO June 2014

Authorities in England were abolished, in line with the with the IOTN, the single-most severe trait is used for
introduction of the UK government’s Health and Social scoring the patient. It is important, particularly when
Care reforms (Ham, 2012), and the South Central PCTs scoring from study models alone, that additional
commissioning intents appeared to have been lost information is provided; for example, information
during this NHS restructuring. In the new era, the would be required regarding the degree of upper labial
commissioning of all dental services and for the interim, segment exposure where present, or functional effects
all oral and maxillofacial services, were now to be such as trauma to the soft tissues where there is an
commissioned centrally by NHS England and imple- increased overbite. This will not be a problem where the
mented locally by the local area teams. In late 2013, IOFTN is used to score the patient at the chairside.
NHS England published its interim clinical commission- Similar limitations also apply to the use of IOTN when
ing policy for orthognathic treatment. Although this scoring more routine malocclusions from study models
interim policy was withdrawn in March 2013, it had alone. Once again, the IOFTN also demonstrates
stated the following (British Association of Oral and moderate to good intra-operator agreement over time
maxillofacial Surgeons (BAOMS), 2014): (0.53–0.80), not too dissimilar to that observed with the
IOTN, with its reported kappa scores of 0.75–0.84
N the IOTN must be 4 or 5;
(Brook and Shaw 1989).
N functional symptoms must have an important impact
After 24 years of service to orthodontics, it is perhaps
on quality of life, which would normally have become
timely that the application of IOTN in clinical practice is
apparent within 5 years of achieving skeletal matur-
being revisited. The concept that any one index should
ity;
not be expected to fit all eventualities when deciding on
N the multidisciplinary team confirms that orthodontic
treatment priorities has recently been made in reference
treatment is insufficient by itself to adequately correct
to secondary care orthodontics (Cousley, 2013). We
these functional symptoms;
therefore feel that the IOFTN is a natural evolution of the
N patients have reached skeletal maturity;
IOTN that should be used when setting treatment
N orthognathic treatment should be low priority on the
priorities for combined orthodontic and orthognathic
grounds of insufficient evidence of functional
care. It is both valid and reliable and, like the IOTN, is
improvement for:
quick and easy to use, thereby fulfilling the essential
requirements of an index. However, the IOFTN concerns
q speech problems;
the functional indicators for orthognathic treatment, and
q jaw pain, particularly that associated with the
other clinical and psychological indicators will also be
temporomandibular joint.
important in the assessment of orthognathic patients.
It would seem that the interim guidance was based on the
earlier South Centrals PCT work and included the IOTN
Conclusions
as a measure of severity and functional need. However,
A new index, the IOFTN, has been developed to help in
the use of IOTN has limitations as a measure of
the prioritization of severe malocclusions not amenable
functional and health need in orthognathic treatment
to orthodontic treatment alone. The index has face and
provision. In particular, some severe dentofacial defor-
content validity and has been shown to have good inter
mities and malocclusions would not be eligible for NHS
and moderate to good intra-operator reliability. As a
funding for orthognathic treatment using IOTN.
result of being an evolution of the IOTN, the format is
Examples include excessive upper labial segment gingival
similar to this index and so it should be easy to
exposure with evidence of gingival and/or periodontal
incorporate within daily orthognathic practice.
effects, complete scissor bites or facial asymmetries with
marked effects on the occlusal plane. In addition, there
was no mention of orthognathic treatment for sleep Disclaimer statements
apnoea. Contributors Each of the authors contributed in the
It is in order to overcome these limitations with the use following manner: substantial contributions to concep-
of IOTN in orthognathic treatment provision that the tion and design, or acquisition of data, or analysis and
IOFTN was developed. The new IOFTN has good face interpretation of data; drafting the article or revising it
and content validity and also demonstrates good to very critically for important intellectual content; and final
good inter-operator agreement (0.64–0.88), similar to approval of the version to be published. The guarantor
the IOTN (0.731–0.797) (Brook and Shaw, 1989). This is is Anthony J. Ireland.
perhaps not surprising, in that the two indices share a Funding None.
similar format, which clinicians are familiar with. As Conflicts of interest There are no conflicts of interest.
 JO June 2014 Open Access Index of Orthognathic Functional Treatment Need 83

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de Oliveira CM. The planning, contracting and monitoring of orthodontic services,
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