OCCLUSAL

INDICES
Dr. Rajshekhar Banerjee
Dept. of Orthodontics and
Dentofacial Orthopaedics,
20-4-2018
ABSMIDS
Contents
1. Introduction
2. Ideal requisites
3. Types of Indices
4. Index of Orthodontic Treatment Need (IOTN)
5. Peer Assessment Rating Index (PAR)
6. Handicapping Malocclusion Assessment Rating
7. Dental Aesthetic Index
8. Orthodontic Treatment Priority Index
9. Occlusal Index
10. Handicapping Labio-Lingual Deviation Index
11. ABO Objective Grading System
12. Index of Complexity Outcome & Need (ICON)
13. Treatment Difficulty Index
14. Conclusion
15. References
Introduction
Definition

‘A numerical value describing the relative

status of a population on a graduated scale
with definite upper and lower limits, which is
designed to permit and facilitate comparison
with the other populations classified by the
same criteria and methods.’
~Russel A.L.
 Definition

In the orthodontic context, index is used to

describe a rating or categorizing system that
assigns a numeric score or alphanumeric
label to a person’s occlusion.
Ideal Requisites of an Index

1. Clarity, simplicity and objectivity

• Rules of the index must be easy to

remember.
• The index should be easy to apply and
simple to minimize time loss.
• The criteria must be unambiguous
with mutually exclusive categories
Ideal Requisites of an Index

2. Validity

• The index must measure what it is

intended to measure.
• Should correspond with the clinical
stages of the disease under study at
each point.
Ideal Requisites of an Index

3. Reliability

• The measurements should reproducible

at different times under different
conditions.
• The same findings should be achieved
by the same or different observers each
time.
Ideal Requisites of an Index

4. Quantifiability

• The index should be amenable to

statistical analysis
Ideal Requisites of an Index

5. Sensitivity

• The index should be able to detect

reasonably small shifts, in either
direction in the group condition.
Ideal Requisites of an Index

6. Acceptability

• Should be acceptable to the subject and

examiner.
• Should not be painful or demeaning to
the subject.
Types of Indices

5 types of indices, each for a distinct purpose.

■ A) Diagnostic classification :
Eg - Angle’s classification being used to
describe incisor and buccal segment
relationships.
These classifications serve their purpose
reasonably well, allowing ease of
communication between orthodontists.
Types of Indices

■ B) Epidemiologic indices :
Records every trait in a malocclusion to
allow estimation of the prevalence of
malocclusion in a given population.
Eg. - Summer’s occlusal index, Little’s
Irregularity index.
Types of Indices

■ C) Treatment need indices :

Developed to allow categorization of
malocclusion according to the level of
treatment need.
Eg. - Handicapping malocclusion
assessment, Grainger's treatment priority
index, Index of orthodontic treatment needs,
Dental aesthetic index
Types of Indices

■ D) Treatment outcome indices :

Assessment of the outcome of treatment or
the changes resulting from treatment.
Eg. - PAR index has been developed
specifically for this purpose, ABO objective
grading system.
Types of Indices

■ E) Treatment complexity Index :

Index of Complexity, Outcome and Need.
Index of
Orthodontic
Treatment Need
(IOTN)
Index of Orthodontic Treatment Need

• Proposed by Peter H. Brook and William

C. Shaw in 1989 .

• Assesses orthodontic treatment need from

anatomic and aesthetic point of view.
Index of Orthodontic Treatment Need

■ It consists of 2 independent components:

1. The Dental Health Component
(DHC)
2. The Aesthetic Component (AC)
Dental Health Component

■ This is categorized in 5 grades ranging

from 1 to 5, based on the evaluation of 5
occlusal traits:
 Missing teeth
 Overjet
 Crossbite
 Contact point displacement
 Overbite
Dental Health Component

■ Measurements can be made directly from

mouth or study models/casts.
■ Only the highest scoring trait need be
recorded, as this determines the grading of
the patient.
■ Order of assessment of trait is not
important.
Aesthetic Component

■ A Standardized Continuum of Aesthetic

Need (SCAN) scale was used.

■ 10 front viewing photographs illustrating

varying degree of occlusion (serves as a
scale) attractive and unattractive occlusion
or casts viewed from front.
Aesthetic Component
■ The rating was based on matching the dental
appearance of the patient with one of the
photographs by an orthodontists or non-
professionals.
■ No profile views are included.
■ 10 photographs were selected on the basis of
the attractiveness ratings of six non dental
judges of a sample of 1000 photographs of 12
year old subjects.
Aesthetic Component

■ A 10-point scale is used.

■ Values are from 0.5 (attractive dental

appearance) to 5 (unattractive dental
appearance)
Reliability

■ According to Brook & Shaw (1989),

reproducibility of the dental health
component of the IOTN was good in ideal
clinical settings.

■ For the aesthetic component, a good

inter/intra examiner reproducibility was
reported when a dentist rated a child for
aesthetic impairment.
Reliability

■ However Buchanan et al (1994), reported

in another study, that there was poor
agreement for the aesthetic component
scored by calibrated examiners from
photographs when compared with scores
recorded clinically or from models.
Modification of IOTN

■ A major modification was suggested both

in the dental health component and
aesthetic component in 1993 to improve
the reliability of these components.

■ In the dental health component (DHC) the

5 grades were reduced to 3.
Modification of IOTN

■ Grade I
■ Grade II No need for
treatment
■ Grade III Borderline
■ Grade IV Definitive need
■ Grade V
Modification of IOTN
■ In the aesthetic component (AC) the 10 point
scale was reduced to a 3 point scale.

• Photographs 1 – 4 : no need for treatment

• Photographs 5 – 7 : Borderline need
• Photographs 8 – 10 : Definitive need

■ These modifications were accepted and are

used as British standards for orthodontic
treatment.
Modification in the Year 2001
■ The Dental Health Component (DHC) was
reduced to 2 grades, The grade no need and
borderline of the previous modification were
combined.
• 0 – no need
• 1 – definite need.

■ In the Aesthetic Component (AC), only those

malocclusions with a definite dental health need
and aesthetic need (photographs 8, 9, 10) are
recorded.
Peer Assessment Rating
Index (PAR Index)
Peer Assessment Rating Index (PAR Index)

■ Given by S. Richmond, W. C. Shaw, K. D.

O'Brien, I. B. Buchanan, R. Jones, C. D.
Stephens, C. T. Roberts, and M. Andrews
in 1992 to record malocclusion at any
stage of treatment.
■ Index was formulated over a series of 6
meetings in 1987 with a group of 10
experienced orthodontists (British
Orthodontic Standards Working Party).
The British Orthodontic Standards Working Party assessing cases projected on four screens, the
results were directly entered onto computer to facilitate intra- and inter-examiner error.
Peer Assessment Rating Index (PAR Index)

■ Over 200 dental casts representing

developmental as well as pre-and post-
treatment stages were examined and
discussed until agreement was reached
regarding the individual features which
would be assessed in obtaining an
estimate of alignment of occlusion.
Description

■ The concept is to assign a score to various

occlusal traits which make up a malocclusion.
■ The individual scores are summed to obtain
an overall total, representing the degree a case
deviates from normal alignment and
occlusion.
■ The score of 0 indicates good alignment and
higher scores (rarely beyond 50) indicates
increased levels of irregularity.
Description

■ The overall score is recorded on the

pre- and post-treatment dental casts.

■ The difference between these scores

represents the degree of improvement as
a result of orthodontic intervention and
active treatment.
Uses a specially designed
ruler which is translucent
and has the PAR
components with
corresponding scores.
3 Segments :-
• Left buccal
• Right buccal
• Anterior
Buccal segments.
Mesial anatomical contact point of the first permanent
molar to the distal anatomical contact point of the canine.
Anterior segment.
Mesial anatomical contact point of the canine on one side
to the mesial anatomical contact point of the canine on
the opposite side.
Occlusal features:
• Crowding
• Spacing
• Impacted teeth
Displacements:
Recorded as the shortest distance between contact points
of adjacent teeth parallel to the occlusal plane. The
greater the displacement the greater the PAR score.
• An impacted tooth is recorded when the space for this
tooth is less than or equal to 4 mm.
• Impacted canines are recorded in the anterior segment.
Impacted scores and displacement scores are added
together to get the final sore.
BUCCAL OCCLUSION

■ The buccal occlusion is recorded for both

left and right sides.

■ Fit of the teeth is determined in the 3

planes of space.

■ Recording zone - Canine to the last molar

(either 1st, 2nd or 3rd)
OVERJET

■ Positive overjet as well as teeth in cross-

bite are recorded.

■ The recording zone is from the left to right

lateral incisors.

■ The most prominent aspect of any one

incisor is recorded.
OVERBITE

■ Overbite is recorded in relation to the

coverage of the lower incisors or the
degree of open bite.

■ The recording zone includes the lateral

incisors.

■ The tooth with the greatest overlap is

recorded.
CENTRELINE

■ Records the centreline discrepancy in

relation to the lower central incisors.
Reliability

■ 4 examiners (2 Orthodontists & 2

postgraduates) measured the PAR scores
of 38 randomly selected cases on 2
occasions 8 weeks apart.

 Intraexaminer reliability – 0.95

 Inter examiner reliability – 0.91
VALIDATION
■ 74 dentists ( 22 orthodontists, 22
specialists, 4 staff members, 15 general
dentists, 11 community dentists) were
invited to participate in the Validation
study.
■ Examined 272 cases representing
treatment undertaken within England &
Wales.
■ Pre & post-treatment PAR scores were
calculated.
VALIDATION

■ Mean weightings were derived for each

component of the PAR index by taking an
average of each individual’s weighting.
■ The weightings which have been derived
reflect the British orthodontic opinion.
■ The Index is flexible enough to change the
weightings for future standards and other
countries.
• In 1995 , Deguzmann et al put forth American
validated version of the index.

Variable British American

weighting weighting
Overjet 6 4.5
Overbite 2 3
Midline 4 3.5
Buccal occlusion 1 2
Upper ant. alignment 1 1
Lower ant. alignment 1 0
Buccal alignment 0 0
■ Treatment results are categorized into 3
categories :
A) Greatly improved– At least 22 points
reduction in PAR index, & 50% reduction in
score.
B) Improved – Less than 22 points
reduction, at least 30% reduction in PAR
score.
C) Worse/No different – Less than 30%
change in score or increase in score.
Modification

■ A.M. Hamdan & W.P. Rock ( EJO 1999)

observed that PAR index cannot be
uniformly applied to all categories of
malocclusion because different occlusal
features vary in importance in different
classes of malocclusion.

■ They put forth a new weighting system for

each category of malocclusion.
Components Class I Class Class Class
II/1 II/2 III
Overjet 2 6 1 5
Overbite 3 2 5 6
Midline 4 2 2 1
Buccal occlusion 1 1 1 1
Upper ant. 2 1 2 1
alignment
Lower ant. 1 1 1 1
alignment
Buccal alignment 0 0 0 0
DRAWBACKS

1. Not sensitive to the details of a finished case.

2. Does not take into account limited treatment
cases.
3. Iatrogenic sequelae like decalcification,
recession, root resorption are not considered.
4. Inclination / angulation of teeth , inappropriate
expansion & treatment mechanics not
evaluated.
5. Soft tissue changes not considered.
Handicapping
Malocclusion
Assessment Rating
Handicapping Malocclusion Assessment Rating

■ This was developed by Salzmann in 1967.

■ Purpose → To provide means for establishing

priority for treatment of handicapping
malocclusion in the individual child.
■ Done according to the severity of the
magnitude of the score obtained in assessing
the malocclusion from dental casts or directly
in the oral cavity.
Handicapping Malocclusion Assessment Rating

■ Handicapping malocclusion & handicapping

dentofacial deformity:
Conditions that constitute a hazard to the
maintenance of oral health & interferes with
the well being of child by adversely affecting
dentofacial aesthetics, mandibular function
or speech.
Scoring
Scoring

■ Points assigned are based on the

deleterious effects on dental health,
stomatognathic function and facial
appearance.

■ This index measures both inter-arch

deviations and intra-arch deviations.
Intra Arch Deviations

■ The model is placed in such a way that the

teeth are facing upwards, in direct view of
the observer.

■ Points are given for

○ Missing teeth
○ Crowded teeth
○ Rotated teeth
○ Open spacing
○ Closed spacing
Inter-Arch Deviation

■ The anterior and posterior segments are

assessed separately.
■ In the anterior segment, we see overjet,
overbite, crossbite and openbite (incisors).
■ In the posterior segment, we look for
crossbite, openbite and antero-posterior
deviation.
Total HMAR Score

■ For this all the three scores are added (i.e.

Intra-arch, Inter arch, Anterior, Posterior)

■ When the score of intra and inter arch is 6 or

more an additional 8 points are added
denoting the presence of each dentofacial
deviation.
Dental Aesthetic
Index (DAI)
Dental Aesthetic Index (DAI)

■ This was developed by N.C. Cons, J.

Jenny and F.C. Kohaut in 1986 to assess
orthodontic treatment needs.

■ It has 2 components:
○ Clinical component
○ Esthetic component
Dental Aesthetic Index (DAI)

■ The Dental Aesthetic Index (DAI) is a

numerical index obtained through
measurement of occlusal traits that are
selected on the basis of their potential for
causing a psychosocial handicap.
■ The DAI provides an assessment of the
relative social acceptability of the dental
appearance, which is based on public
perception of dental esthetics.
Procedure

■ Can be obtained from casts or intra-orally

(without use of radiographs).
■ The 10 occlusal traits are listed and scores
are given. These scores are then multiplied
by their actual/rounded weights
(regression coefficient).
■ This product is added to a constant
number 13 and DAI is computed.
Occlusal traits:

1. Missing teeth (incisors, cuspids and bicuspids)

2. Anterior crowding
3. Anterior spacing
4. Midline diastema between maxillary centrals
5. Largest anterior irregularity in maxilla
6. Largest anterior irregularity in mandible.
7. Overjet
8. Underjet
9. Anterior openbite
10. Anteroposterior molar relation.
Components

1. Missing teeth (In, C, Bi) in the maxillary

and mandibular arches.
2. Crowding in incisor segments
○ 0 – no crowding
○ 1 – 1 segment crowded
○ 2 – 2 segments crowded
Components

3. Assessment of spacing in incisor segments

○ 0 – no spaced segments
○ 1 – one spaced segment
○ 2 – more than one spaced segments
4. Measurement of midline diastema in
millimeters
5. Largest anterior irregularity segment in the
maxilla in millimeters
Components

6. Largest anterior irregularity segment in the

mandible in mm.
7. Measurement of anterior maxillary overjet
in mm.
8. Measurement of anterior mandibular
overjet in mm.
9. Measurement of vertical anterior openbite.
Components

10. Assessment of anteroposterior molar

relation (largest deviation from left or right
side).
○ 0 – normal
○ 1 – ½ cusp mesial/distal or more
○ 2 – 1 full cusp or more mesial/distal
Modification

Space from recently exfoliated deciduous

tooth is not scored as missing (permanent
erupting in a short time).
SCORE GRADING

■ Score 25 and below – Minor malocclusion

no treatment needed
■ Scores 26 to 30 – Definite malocclusion,
elective treatment
■ Scores 30 to 35 – severe malocclusion,
treatment highly desirable
■ Score above 36 – severe handicapping
malocclusion, treatment mandatory.
Orthodontic
Treatment Priority
Index (TPI)
Orthodontic Treatment Priority Index (TPI)

■ Given by R. M. Grainger in 1967 .

■ Provides weighted sub scores for

describing overjet, overbite or open bite,
tooth displacement, posterior crossbites,
as well as summary scores reflecting the
overall severity of the malocclusion.
Orthodontic Treatment Priority Index (TPI)

■ This index consists of 10 manifestations

of malocclusion and includes seven
syndromes.
 the incisor relationship horizontally
(underjet, overjet)
 vertically (overbite, open bite)
 the occlusion of the buccal segments
(posterior crossbite)
 Tooth displacement (rotation and crowding)
Orthodontic Treatment Priority Index (TPI)

Overjet:
Measured perpendicular to coronal plane.

Overbite or Open bite:

Amount of vertical overlap of the maxillary
central incisor over the mandibular central
incisor.
Models put in centric occlusion.
Orthodontic Treatment Priority Index (TPI)

Tooth displacement :
Sum of the number of teeth noticeably
rotated or displaced from ideal alignment,
plus 2 times the number of teeth rotated
more than 45º or displaced more than 2mm.
Orthodontic Treatment Priority Index (TPI)

Mesial and distal occlusion:

This depends on the molar relationship
(deciduous 2nd molars/permanent 1st molars)

Buccal/lingual crossbites:
Number of maxillary teeth in the buccal
segments (according to their position).
Measurement is positive for buccal crossbite,
negative when lingual crossbite is observed.
Orthodontic Treatment Priority Index (TPI)

Congenitally absent teeth:

Findings are made sure using a radiograph
SCORING

Total scores on TPI range from 0 to 10 or more,

with higher scores representing more severe
malocclusion.

0 - 1 : No treatment need,
2 – 3 : Minimal need,
4 – 6 : Moderate need,
>6 : definite need.
The Occlusal Index
The Occlusal Index

■ The Occlusal Index was developed to

overcome the lack of consensus among
investigators concerned with measuring
occlusion for epidemiological purposes.

■ Given by Chester J. Summers (1971)

The Occlusal Index

■ 9 characteristics are scored in the occlusal

index –
1. Dental age
2. Molar relation
3. Overbite
4. Overjet
5. Posterior cross-bite
6. Posterior open-bite
7. Tooth displacement (actual and potential)
8. Midline relations
9. Missing permanent teeth
1. Dental Age

■ Dental age 0: Begins at birth and ends

with the eruption of the first deciduous
tooth.

■ Dental age I: Begins with the eruption of

first deciduous tooth, ends when all
deciduous teeth are in occlusion.
1. Dental Age

■ Dental age 2: Begins when all deciduous

teeth are in occlusion, ends with eruption
of first permanent tooth.

■ Dental age 3: Begins with eruption of first

permanent tooth, ends when all permanent
incisors and first molars are in occlusion.
1. Dental Age

■ Dental age 4: Begins when all permanent

central and lateral incisors and first molars
are in occlusion and ends with the eruption
of any permanent canine or premolar.

■ Dental age 5: Begins with eruption of any

permanent canine, premolar, ends when all
permanent canines & premolars are in
occlusion.
1. Dental Age

■ Dental age 6: Begins when all permanent

canines and bicuspids are in occlusion.
2. Molar Relation
2. Molar Relation
3. Overbite

■ Scored as the vertical distance from the

incisal edge of the maxillary central
incisor to the incisal edge of the
mandibular central incisor when the jaws
are in “centric occlusion.”
4. Overjet

■ Scored as the horizontal distance from the

labial surface of the maxillary central
incisor to the labial surface of the
mandibular central incisor in mm.

■ The scores may be positive, zero, or

negative.
5. Posterior Cross-bite

■ May be dental, functional or osseous.

• Osseous cross bites involve a gross
mediolateral disharmony of the craniofacial
skeleton.
• Dental cross-bites involve a tipping of
teeth as a result of space insufficiency.
• Functional cross-bites involve muscular
adjustment to tooth interferences.
6. Posterior Open Bite

■ Posterior open-bite may be unilateral or

bilateral and may accompany an anterior
open-bite (negative overbite).

■ Scored as either present or not present

and. If present, as either unilateral or
bilateral.
7. Tooth Displacement

■ Divided into Mixed and Non-Mixed

dentitions.

■ Non mixed
• 1.5 – 2mm deviation or 35º to 45º of
rotation . Scored as 1 or single weight.
• B) >2mm deviation or >45º of rotation.
Scored as 2 or double weight.
7. Tooth Displacement

■ Mixed dentition :
1. Tooth displacement not associated with space
deficiency: Deviation 1.5mm or more or rotated
35º or more. These teeth are weighted (1 or 2) ,
as in displacement scoring procedure for non
mixed dentition.
2. Tooth displacement associated with space
deficiency: Assess space deficiency by
measuring mesio-distal widths of permanent
teeth & subtract the length of arch perimeter.
7. Tooth Displacement

■ If the width of teeth exceeds arch perimeter,

tooth displacement will occur.

■ Weighted value for space deficiency will be

similar to weighted value when examined during
permanent dentition.
8. Midline Relations

■ DIASTEMA: Defined as the space, in

mm, between the two maxillary central
incisors, either deciduous or permanent,
which have erupted into occlusion.
■ If the incisors are not in occlusion (dental
age III), the observation is not recorded.
When the diastema equals or exceeds 2
mm, it is given a weight in the Occlusal
Index.
8. Midline Relations

■ JAW DEVIATION: Defined as the

distance, in mm, between the midpoint of the
two maxillary central incisors and the
midpoint of the two mandibular central
incisors in the horizontal plane in centric
occlusion.
■ If any central incisor is missing, the
procedure is not recorded. Jaw deviations of
3 mm or more are given a weight in the
Occlusal Index.
9. Missing Permanent Teeth

■ Only missing maxillary incisor teeth

which have not been replaced by a
prosthesis are scored.
Calculating scores of the Occlusal Index

■ It incorporates separate weighting

mechanisms for each stage :
a) Deciduous dentition stage – dental ages I &
II.
b) Mixed dentition stage – dental ages III, IV,
V.
c) Permanent dentition stage – dental age VI.
Calculating scores of the Occlusal Index

■ Occlusal index contains 2 divisions & 7

syndromes.
 Divisions I & II – Normal or distal molar
relation.
 Division III (mesial molar relation)
Interpretation of Scores

The subjective classification resulted in the

following classes :
1. Good occlusions - No evidence of an occlusal
disorder.
2. No treatment - Slight deviations in the occlusion,
but no treatment indicated at this time.
3. Minor treatment - Minor deviations in the
occlusion which could be remedied by simple
treatment (that is, space regainers or removable
appliances).
Calculating scores of the Occlusal Index

■ Calculating form to be used is determined by

the dental age of the subject.
■ One simply scores each examination item (1 to
17) , circles the score on the form (Observation
score), & places the weighted score (code)
listed below the observation score in the
appropriate column under the appropriate
occlusal syndrome.
■ The sum of all weights in all columns is then
determined.
 Calculating scores of the Occlusal Index

■ To arrive at the total score, molar relation is

ascertained. The weights of all measurements are
placed in the syndromes of that division, and the
score are derived only from those syndromes.
■ If division I & II is circled, the score is score of
the syndrome (A to E) with highest score plus one
half of the total scores of the remaining syndromes.
■ If division III – score of syndrome with highest
score (F or G)
Interpretation of Scores

The subjective classification resulted in the

following classes :
4. Definite treatment - Major deviations in the
occlusion which could be remedied by major
treatment (that is, treatment which would
include banding of many teeth).
5. Worst occlusions - Major deviations in the
occlusion which could be remedied by major
treatment; these occlusions were highly
disfiguring to the patient and would probably
rank first in treatment priority.
Malocclusion indices: A comparative evaluation
John M. Grewe and Donald V. Hagan (AJODO March, 1972)

■ They compared Handicapping

Malocclusion Assessment index, Occlusal
index & Treatment Priority index to
estimate precision as well as chance error ,
systematic error or any bias in their use.
■ They concluded that none of the 3 indices
can be selected over the other, with regard
to precision or intra/inter examiner
differences.
Malocclusion indices: A comparative evaluation
John M. Grewe and Donald V. Hagan (AJODO March, 1972)

■ From all 3 indices Occlusal index showed

least amount of bias.
Handicapping
Labio-lingual
Deviation Index
Handicapping Labio-lingual Deviation Index

■ Introduced by Harry L. Draker in 1960.

■ Was proposed to select subjects with

severe or handicapping malocclusion &
dento-facial anomalies.

■ Applicable only to permanent dentition.

 Handicapping Labio-lingual Deviation Index

■ 3 planes –
Sagittal plane,
F–H plane ,
Orbital plane
are the basis for
the HLD index
measurements.
Handicapping Labio-lingual Deviation Index

■ The intention of the index is to measure

the presence or absence, and the degree, of
the handicap caused by the components of
the index, and not to diagnose
“malocclusion.”
Method

■ All measurements are made with a Boley

gauge scaled in millimeters.
Components

1. Cleft Palate : Described as malocclusions

resulting from serious structural deformities
involving growth & development of
mandible & maxilla
2. Traumatic deviation : Refers to eg – loss of
a premaxilla segment by burns or by
accident, results of Osteomyelitis or other
gross pathology.
(The presence of either palate or traumatic deviation
is indicated by an X.)
Components

3. Overjet : Measured with the patient in

centric relationship. Measurement can be
applied to a protruding single tooth or to a
whole arch. Measurement is read & rounded
off to the nearest mm & recorded.
 Components

4. Overbite :
Measurement is
rounded off to the
nearest mm &
recorded.
Components

5. Mandibular Protrusion : Measured from

the labial of the lower incisor to the labial
of the upper incisor.
Components

6. Anterior Open Bite: It is measured from

edge to edge, in millimeters.
Components

7. Labio-lingual spread: Total distance

between the most protruded & the lingually
displaced anterior is measured.
Score Interpretation

■ Score of 13 & over constitutes a ‘physical

handicap’.
Codes used in HLD index

 0 = Condition absent
 X = Condition present
 M = Mixed dentition (to be indicated if
present)
 A = Clinical approval
 D = Clinical disapproval
ABO Objective
Grading System
(OGS)
Objective Grading System (OGS)

■ In 1994, the American Board of

Orthodontics began investigating methods
of making the phase III examination more
objective.

■ Efforts were directed at developing an

objective method of evaluating the dental
casts and intraoral radiographs.
Objective Grading System (OGS)

■ An ABO committee was formed in 1994,

to begin field testing precise methods of
objectively evaluating posttreatment
dental casts and panoramic radiographs

■ This scoring system has been developed

systematically through a series of 4 field
tests over a period of 5 years.
Objective Grading System (OGS)

■ First field test : 1995 ABO phase III

examination-
○ 100 cases were evaluated.
○ A series of 15 criteria were measured on final
dental casts and panoramic radiographs.
○ Data showed that 85% of the inadequacies in the
final result occurred in 7 of 15 criteria :
(Alignment, Marginal ridges, buccolingual
inclination, overjet, occlusal relationships,
occlusal contacts, root angulation).
Objective Grading System (OGS)

■ Second field test : 1996 Phase III

examination.
○ 300 sets of final casts evaluated by a
subcommittee of 4 directors, to verify
results of previous test and to determine if
multiple examiners could score the records
reliably & consistently.
Objective Grading System (OGS)

■ Second field test : 1996 Phase III

examination.
○ Majority of the inadequacies in the final
results occurred in the same 7 categories,
but the committee had difficulty establishing
adequate inter-examiner reliability.
○ They recommended a measuring instrument
to be developed to make the measuring
process more reliable.
Objective Grading System (OGS)

■ Third field test : 1997 ABO phase III

examination.
○ Performed with the modified scoring system
and addition of an instrument to measure the
various criteria more accurately.
○ A calibration session preceded the
examination to establish more accurate use
of the measuring instrument and improve
the reliability of the directors.
Objective Grading System (OGS)

■ Third field test : 1997 ABO phase III

examination.
○ All the directors participated
○ 832 casts and radiographs were evaluated.
○ Interproximal contacts was added as the 8th
criteria in the scoring system.
Objective Grading System (OGS)

■ Fourth & Final test : 1998 ABO exam.

○ All the directors participated.
○ New and improved measuring instrument
was used. An extensive training and
calibration session was performed before the
actual examination.
○ Based on the collective & cumulative results
of these extensive field tests, the Board
officially initiated the use of this Objective
Grading System in 1999.
Criteria

1. Alignment
2. Marginal ridges
3. Buccolingual inclination
4. Occlusal relationships
5. Occlusal contacts
6. Overjet
7. Interproximal contacts
8. Root angulation
1. Alignment

■ In the anterior region, the incisal edges

and lingual surfaces of the maxillary
anterior teeth and the incisal edges and
labial-incisal surfaces of the mandibular
anterior teeth were chosen as the guide to
assess anterior alignment.
1. Alignment

■ In the maxillary posterior region, the

mesiodistal central groove of the
premolars and molars is used to assess
adequacy of alignment. In the mandibular
arch, the buccal cusps of the premolars
and molars are used to assess proper
alignment.
1. Alignment

■ The results of the four field tests show that

the most commonly mal-aligned teeth
were the maxillary and mandibular lateral
incisors and second molars, which
accounted for nearly 80% of the mistakes.
2. Marginal Ridges

■ Marginal ridges are used to assess proper

vertical positioning of the posterior teeth.
■ In patients with no restorations, minimal
attrition, and no periodontal bone loss, the
marginal ridges of adjacent teeth should
be at the same level.
2. Marginal Ridges

■ In a periodontally healthy individual, this

will result in flat bone level between
adjacent teeth.
■ It would also be helpful in establishing
proper occlusal contacts.
3. Buccolingual Inclination

■ In order to establish proper occlusion in

maximum intercuspation and avoid
interferences, there should not be a
significant difference between the heights
of the buccal and lingual cusps of the
maxillary and mandibular molars and
premolars.
4. Occlusal Relationship

■ Used to assess the relative anteroposterior

position of the maxillary and mandibular
posterior teeth.
■ Results of previous field tests have shown
that the most verifiable method of scoring
this criteria is to use Angle’s relationship.
4. Occlusal Relationship

■ The mesiobuccal cusp of the maxillary first

molar must align within 1 mm of the buccal
groove of the mandibular first molar.
5. Occlusal Contacts

■ Measured to assess the adequacy of the

posterior occlusion.

■ A major objective of orthodontic treatment

is to establish maximum intercuspation of
opposing teeth.
5. Occlusal Contacts

■ The functioning cusps are used to assess the

adequacy of this criterion; the buccal cusps
of the mandibular molars and premolars and
the lingual cusps of the maxillary molars and
premolars.
5. Occlusal Contacts

■ If cusp form is small or diminutive, that cusp

is not scored.
■ Most common problem area has been
inadequate contact between maxillary and
mandibular second molars.
6. Overjet

■ Assesses the relative transverse

relationship of the posterior teeth and the
anteroposterior relationship of the anterior
teeth.

■ In the posterior region, the mandibular

buccal cusps and maxillary lingual cusps
are used to determine proper position
within the fossae of the opposing arch.
6. Overjet

■ In the anterior region, the mandibular

incisal edges should be in contact with the
lingual surfaces of the maxillary anterior
teeth.

■ In past field tests, the common mistakes in

overjet have occurred between the
maxillary and mandibular incisors and
second molars.
7. Interproximal Contacts

■ Used to determine if all spaces within the

dental arch have been closed.
■ Persistent spaces between teeth after
orthodontic therapy are not only unaesthetic,
but can lead to food impaction.
8. Root Angulation

■ Assesses how well the roots of the teeth

have been positioned relative to one
another.
■ Panoramic radiographs are the best means
possible for making this assessment.
■ Properly angulated roots means sufficient
bone present between roots; which is
important to patients susceptible to
periodontal bone loss.
GUIDE FOR GRADING CLINICAL CASE
REPORTS

■ MODEL ANALYSIS
1. Alignment
• If all teeth are in alignment or within 0.50 mm of
proper alignment, no points are subtracted from
the candidate’s score.
GUIDE FOR GRADING CLINICAL CASE
REPORTS

• If the mesial or distal alignment at any of the

contact points is 0.50 mm to 1 mm deviated from
proper alignment, 1 point shall be subtracted for
the tooth that is out of alignment.
• If adjacent teeth are out of alignment, then 1
point should be subtracted for each tooth.
GUIDE FOR GRADING CLINICAL CASE
REPORTS

• If the discrepancy in alignment of a tooth at the

contact point is greater than 1 mm, then 2 points
shall be subtracted for that tooth .

• No more than 2 points shall be subtracted for any

tooth.

• The total number of deductions shall be

subtracted from 64 to give the score for
alignment.
GUIDE FOR GRADING CLINICAL CASE
REPORTS

2. Marginal Ridge
• The marginal ridge will be considered as the
most occlusal point that is within 1 mm of the
contact at the occlusal surface of adjacent teeth.
• If adjacent marginal ridges deviate from 0.50 to 1
mm , then 1 point shall be subtracted for that
interproximal contact.
• If the marginal ridge discrepancy is greater than
1 mm , then 2 points shall be subtracted for that
interproximal contact
GUIDE FOR GRADING CLINICAL CASE
REPORTS

• No more than 2 points will be subtracted for any

contact point.

• The total number of deductions shall be

subtracted from 32 to give the score for marginal
ridges.
GUIDE FOR GRADING CLINICAL CASE
REPORTS

3. Buccolingual Inclination
• Assessed by using a flat surface that is extended
between the occlusal surfaces of the right and left
posterior teeth.

• When positioned in this manner, the straight edge

should contact the buccal cusps of contralateral
mandibular molars. The lingual cusps should be
within 1 mm of the surface of the straight edge .
GUIDE FOR GRADING CLINICAL CASE
REPORTS

• In the maxillary arch, the straight edge should

contact the lingual cusps of the maxillary molars
and premolars. The buccal cusps should be
within 1 mm of the surface of the straight edge .

• If the mandibular lingual cusps or maxillary

buccal cusps are more than 1 mm, but less than 2
mm from the straight edge surface , 1 point shall
be subtracted for that tooth.
GUIDE FOR GRADING CLINICAL CASE
REPORTS

• If the discrepancy is greater than 2 mm , then

2 points are subtracted for that tooth. No
more than 2 points shall be subtracted for any
tooth.

• The total number of deductions are subtracted

from 40 to give the score for posterior
inclination.
GUIDE FOR GRADING CLINICAL CASE
REPORTS

4. Occlusal Contacts
• If the cusps are in contact with the opposing arch,
no points are deducted. If a cusp is out of contact
with the opposing arch and the distance is 1 mm
or less , then 1 point is subtracted for that tooth.
• If the cusp is out of contact and the distance is
greater than 1 mm , then 2 points are subtracted
for that tooth. No more than 2 points are
subtracted for each tooth.
GUIDE FOR GRADING CLINICAL CASE
REPORTS

• The total number of deductions are subtracted

from 64 points to give the score for occlusal
contacts.
GUIDE FOR GRADING CLINICAL CASE
REPORTS

5. Occlusal Relationship
• If the maxillary buccal cusps deviate between 1
and 2 mm from the positions, then 1 point shall
be subtracted for that tooth.
• If the buccal cusps of the maxillary premolars or
molars deviate by more than 2 mm from ideal
position , then 2 points shall be subtracted for
each tooth that deviates.
• No more than 2 points shall be subtracted for
each tooth.
GUIDE FOR GRADING CLINICAL CASE
REPORTS

• The total number of deductions are subtracted

from 24 to give the score for occlusal
relationships.
GUIDE FOR GRADING CLINICAL CASE
REPORTS

6. Overjet
• If the mandibular buccal cusps deviate 1 mm or
less from the center of the opposing tooth , 1
point is subtracted for that tooth.
• If the position of the mandibular buccal cusps
deviates more than 1 mm from the center of the
opposing tooth , two points are subtracted for
that tooth.
• No more than 2 points are subtracted for any
tooth.
GUIDE FOR GRADING CLINICAL CASE
REPORTS

• In the anterior region, if the mandibular canines

or incisors are not contacting lingual surfaces of
the maxillary canines and incisors and the
distance is 1 mm or less , then 1 point is
subtracted for each tooth.
• If the discrepancy is greater than 1 mm , then 2
points are subtracted for each tooth.
• The total number of deductions are subtracted
from 32 to give the score for overjet.
GUIDE FOR GRADING CLINICAL CASE
REPORTS

7. Interproximal Contacts
• If no interproximal spaces exist, then no points
are subtracted.
• If up to 1 mm of interproximal space exists
between two adjacent teeth , then 1 point is
subtracted.
• If more than 1 mm of space is present between
two teeth , then 2 points are subtracted
GUIDE FOR GRADING CLINICAL CASE
REPORTS

• No more than 2 points are subtracted for any

contact that deviates from ideal.
• The total number of deductions are subtracted
from 60 to give the score for interproximal
contacts.
GUIDE FOR GRADING CLINICAL CASE
REPORTS

■ RADIOGRAPHIC ANALYSIS
Root Angulation
• The roots of the maxillary and mandibular teeth
should be parallel to one another and oriented
perpendicular to the occlusal plane .
• If this situation exists or if a deviation of the apex
is 1 mm or less, then no points are subtracted.
GUIDE FOR GRADING CLINICAL CASE
REPORTS

• If a root is angled to the mesial or distal on the

panoramic radiograph and if the discrepancy is
mild with the apex of the affected tooth greater
than 1 mm but less than 2 mm from its ideal
relationship , then 1 point is subtracted for that
tooth.
GUIDE FOR GRADING CLINICAL CASE
REPORTS

• If the discrepancy is greater than 2 mm , then 2

points are subtracted for that tooth.
• The total number of deductions are subtracted
from 64 to give the score for root angulation.
A, 1 mm in width and measures discrepancies in
alignment, overjet, occlusal contact, interproximal contact,
and occlusal relationships;

B, steps measure 1 mm in height and are used to determine

discrepancies in mandibular posterior buccolingual
A: 1 mm in width and measures discrepancies in
alignment, overjet, occlusal contact, interproximal
contact, and occlusal relationships;
B: Steps measure 1 mm in height and are used to
determine discrepancies in mandibular posterior
buccolingual inclination.
C: Steps measure 1 mm in height and are used to
determine discrepancies in marginal ridges.
D: Steps measure 1 mm in height and are used to
determine discrepancies in maxillary posterior
buccolingual inclination.
Passing Score

■ In general, a case report that loses more

than 30 points will fail.
■ A case report that loses less than 20
points will generally pass that portion of
the phase III examination.
■ However, this figure only represents a part
of the overall score for each case report.
Passing Score

■ The quality of the records, appropriateness

of the treatment plan, and objectives for
positioning of the maxilla, mandible,
maxillary dentition, mandibular dentition,
and facial profile are also carefully
scrutinized.
INDEX OF
COMPLEXITY,
OUTCOME AND
 INDEX OF COMPLEXITY, OUTCOME AND NEED

■ Assesses the treatment need, complexity,

treatment improvement, outcome based on
international professional opinion, intended
for use in the context of specialist practice.
■ Professional perceptions of treatment need
and treatment outcome were solicited by
asking an international panel of 97
orthodontists from 9 countries to judge a
diverse sample of 240 study casts.
INDEX OF COMPLEXITY, OUTCOME AND NEED

■ Occlusal traits scored include:

a) Upper and lower labial segment
alignment.
b) Anterior and vertical relationship,
centreline, impacted teeth, upper and
lower buccal segment alignment*, buccal
segment antero-posterior relationship*,
buccal segment vertical relationship*,
crossbite, missing teeth (excluding 3rd
molar)
INDEX OF COMPLEXITY, OUTCOME AND NEED

c) Aesthetic assessment based on IOTN

aesthetic component, overjet in mm,
reverse overjet in mm, upper and lower
incisor inclination relative to the occlusal
plane, overall upper arch and lower
crowding/spacing, lip competency.
COMPONENTS

1. Dental Aesthetics
○ The dental aesthetic component of the IOTN (Shaw
et al.,1991a) is used.
○ 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.
○ 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.
COMPONENTS

2. Crossbite
i. Present if a transverse relation of cusp to cusp
or worse exists in the buccal segment. This
includes buccal and lingual crossbites
consisting of one or more teeth, with or without
mandibular displacement.
ii. If crossbite is present, a raw score of 1 is given
which is multiplied by the weighting of 5.
iii. A score of 0 is given if crossbite is not present.
COMPONENTS

3. Anterior Vertical Relationship

○ This trait includes both open bite and deep
bite. If both are present, only the highest
scoring raw score is counted.
○ Positive overbite is measured at the deepest
part of the overbite on incisor teeth.
○ The raw score obtained is multiplied by 4.
COMPONENTS

4. Upper Arch Crowding/Spacing

○ The sum of the mesio-distal crown diameters is
compared to the available arch circumference,
mesial to the last standing tooth on either side.
○ An impacted tooth in either the upper or lower
arch, is scored the maximum for crowding. A tooth
must be unerupted to be defined as impacted.
○ Retained deciduous teeth (i.e. without a permanent
successor) and erupted super-numerary teeth
should be scored as space unless they are to be
retained.
COMPONENTS

4. Upper Arch Crowding/Spacing

○ In transitional stages average canine and premolar
widths can be used to estimate the potential
crowding. Suggested averages are 7 mm for
premolar and lower canine and 8 mm for upper
canine. The presence of erupted antimeric teeth
allows more accurate estimation for this purpose.
○ Spacing due to teeth lost to trauma and exodontia
is also counted.
○ Once the raw score has been obtained it is
multiplied by the weighting 5.
COMPONENTS

5. Buccal Segment Antero-posterior

Relationship
○ The scoring zone includes the canine
premolar and molar teeth. The antero-
posterior cuspal relationship is scored
according to the given protocol for each side
in turn.
○ The raw scores for both sides are added
together and then multiplied by the weighting
3.
If the summary score is greater than 43, then treatment is
indicated.
If the summary score (in post treatment casts) is less than
31, the outcome is acceptable.
Advantages

■ Relatively simple to use requiring no

hierarchy and having relatively few traits
to measure.
■ Most of the measurements are common to
components of PAR and IOTN.
■ It resolves the possible conflict between
treatment need and outcome
classifications.
■ Relatively quick to execute.
Advantages

■ Requires no measurement tools other than an

ordinary mm ruler and the aesthetic
component scale.
■ Valid for both treatment need, complexity
and outcome.
Treatment Difficulty
Index (TDI)
for unerupted
maxillary canines
TREATMENT DIFFICULTY INDEX (TDI)

■ The objective of this index was to produce

a treatment difficulty index (TDI) that
could be used to measure the difficulty
that would be expected during the
alignment of an unerupted maxillary
canine.
‘Vertical rule of thirds’ (McSherry, 1996)

It has been reported by McSherry that the

higher above the occlusal plane the canine is
positioned, the poorer the prognosis for
alignment.
a) Good prognosis – If canine cusp tip is at level
of amelocemental junction of the adjacent
incisor.
b) Fair prognosis – Cusp tip of canine at a level
of half the root length of adjacent incisor.
c) Poor prognosis – Cusp tip lay against apical
third of adjacent incisor root.
Factors

1. Rotation.
2. Angulation to midline.
3. Age of patient.
4. Coincidence of arch midlines.
5. Alignment and spacing of the upper labial
segment.
6. Vertical height.
7. Bucco-palatal position.
8. Condition of primary canine.
9. Missing teeth.
10. Horizontal position.
To simplify calculation of a treatment difficulty
score, regression coefficients were rounded to the
nearest half to produce the regression equation:

Difficulty score
= Constant –8 + Horizontal position 2.0 + Age
1.5 + Vertical height 1.5 + Bucco-palatal
position 1.5 + Rotation 1.0 + Midline 1.0 +
Angulation 1.0 + Alignment 0.5
Comparing and contrasting two orthodontic indices, the Index
of Orthodontic Treatment Need and the Dental Aesthetic Index

Jenny J, Cons NC. AJODO, October

1996
■ In the IOTN, the aesthetic component is a
separate instrument from the dental health
component. The DAI links people's
perceptions of aesthetics with anatomic trait
measurements by regression analysis to
produce a single score obviating the need.
In the IOTN, for two separate scores that
cannot be combined.
Comparing and contrasting two orthodontic indices, the Index
of Orthodontic Treatment Need and the Dental Aesthetic Index

Jenny J, Cons NC. AJODO, October

1996
■ Both components of the IOTN have only
three grades, "no need,“ "borderline need,"
and "definite need."
■ The IOTN cannot rank order cases with
greater or lesser need for treatment within
grades. In contrast, DAI scores can be rank
ordered on a continuous scale and can
differentiate cases within severity levels.
Relationship between Index Of Complexity Outcome and Need,
Dental Aesthetic Index, Peer Assessment Rating Index, and
American Board of Orthodontics Objective Grading System
Onyeaso and Begole, AJODO, February 2007
•The ICON can substitute for the DAI to measure orthodontic treatment
need. A value greater than 43 for the ICON defines need for treatment, as
does a DAI score of 26 or above. The relationship between these 2 indexes
was statistically significant (P .001).
•The PAR had a close relationship with the ICON in this study; thus, the
ICON can be used to assess orthodontic treatment outcome.
•The ABO-OGS requires more stringent standards than the PAR or the
ICON for assessing the outcome of orthodontic treatment.
•Overall agreement between the ICON and the other indexes assessed in
this study was good. Hence ICON appears to be a reasonable means of
assessing the standard of orthodontic treatment in terms of complexity, need,
and outcome rather than using various indexes. Use of the ICON will
encourage international comparison and professional standardization.
 CONCLUSION

Indices in orthodontics allows a more uniform

interpretation and application of criteria for
treatment needs and changes.
Still there is a need of a development of index
which can be universally accepted in terms of
reliability and validity.
There is a need to improve diagnostic criteria
and develop a common approach for assessing
treatment need.
References
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American Journal of Orthodontics. 1968 Oct 1;54(10):749-65.
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• ENG F. The development of the index of complexity, outcome and need (ICON). Journal of
orthodontics. 2000;27:149-62.
• Pitt S, Hamdan A, Rock P. A treatment difficulty index for unerupted maxillary canines. The
European Journal of Orthodontics. 2005 Jul 25;28(2):141-4.
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Orthodontic Treatment Need and the Dental Aesthetic Index. American journal of
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Thank you!