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  • 1. UNIVERSITY OF GLASGOW Orthodontic Indices Personal notes Mohammed Al Muzian 5/2/2013 An Orthodontic index or a malocclusion index can be defined as a means of objectively assessing occlusal status.
  • 2. Mohammed Almuzian, University of Glasgow 1 List of contents Definition Uses of orthodontic indices 1. Epidemiological 2. Clinical Assessment 3. Uniformity in inter-disciplinary communication and description of a malocclusion General requirement of an index Types of indices 1. Classification indices 2. Diagnostic indices 3. Treatment assessment (need, complexity and outcome) 4. Cleft outcomes 5. Oral health indices Angle’s classification • Some modification has been added like: • Advantage • Drawbacks Incisor classification • Some modification has been added like: Skeletal classification Index of Orthodontic Treatment Need 1. The aesthetic component Treatment priority and need according to AC 2. The dental health component
  • 3. Mohammed Almuzian, University of Glasgow 2 • Treatment priority and need according to DHC • Advantages • Disadvantages: • Reproducibility of the IOTN: 1. Dental Health Component 2. Aesthetic Component:  Missing teeth (5.i, 5.h or 4.h)  Impeded eruption (5.i)  Hypodontia (5.h or 4.h)  Overjet (2.a, 3.a, 4.a, 5.a, 2b, 3b, 4b, 4m,5m)  Crossbite (2.c, 3.c, 4.c)  Displacement of contact points (2.d, 3.d, 4.d)  Overbite and Open bite (2.e/f, 3.e/f, 4.e/f)  Buccal occlusion (2.g)  Submerging teeth (5.S)  Tipped teeth (4.t)  Supernumerary teeth (4.x) Peer Assessment Rating (PAR) Reliability  Buccal and anterior segments  Buccal occlusion  Overjets  Overbite  Centrelines Advantages Disadvantages Outcome assessment
  • 4. Mohammed Almuzian, University of Glasgow 3 Index Of Complexity, Outcome And Need (ICON) ABO Discrepancy Index (ABO DI) Disadvantages of ABO DI Advantages of ABO DI Handicapping Malocclusion Assessment Record (HMAR) Irregularity index Crowding index The validity of maxillary expansion indices, O'Reilly, 1995 A treatment difficulty index for unerupted maxillary canines Plaque index Gingival index Handicapping Labio-Lingual Deviation (HLD) Swedish Index (Need For Treatment Index) Treatment Priority Index (TPI)
  • 5. Mohammed Almuzian, University of Glasgow 4 Orthodontic Indices Definition An Orthodontic index or a malocclusion index can be defined as a means of objectively assessing occlusal status. Uses of orthodontic indices 1. Epidemiological A. determine the prevalence and incidence of occlusal anomalies B. economic health care resource planning (financially and in terms of manpower) C. for academic research 2. Clinical Assessment A. Classification of malocclusion (Angle classification, incisor classification by BSI, 1983) B. Diagnostic (Occlusal index) C. Treatment Need or priority (e.g. IOTN). D. Treatment Complexity /difficulty (NB: ICON tries to address Complexity, Outcome & Need). E. Treatment Outcome /success (PAR). 3. Uniformity in inter-disciplinary communication and description of a malocclusion Generalrequirement of an index 1. Reliable 2. Reproducible: closeness of successive evaluation.
  • 6. Mohammed Almuzian, University of Glasgow 5 3. Valid: the index should measure what it was intended to measure. 4. Universally acceptable to profession and public 5. Require minimal adjustment. 6. Simple to administer. 7. Cheap. Types of indices 1. Classificationindices a) Skeletal classification b) Soft tissue classification c) Occlusal classification:  Angle’s Classification  Incisor Classification  Canine Classification 2. Diagnostic indices a) Occlusal index b) Handicapping Malocclusion Assessment Record (HMAR) 3. Treatment assessment(need, complexity and outcome) a) IOTN b) Irregularity Index c) Peer Assessment Rating (PAR) d) ICON 4. Cleft outcomes a) GOSLON Yardstick b) 5 year Old’s Index c) Bergalnd index for SABG
  • 7. Mohammed Almuzian, University of Glasgow 6 d) Kindealan index for SABG 5. Oral health indices a) Plaque Index b) CPITN c) Gingival Index Angle’s classification a) This classification is used in orthodontics to assess the anterior posterior relationship with regards to the lower first permanent molar as a key. b) Three classes were described by Angle (1899):  Class I (neutrocclusion): when the mesiobuccal cusp of the upper first permanent molar occlude with the buccal groove of the lower first permanent molar.  Class II (distocclusion/ Post-Normal): when the mesiobuccal cusp of the upper permanent first molar at least one cusp width mesial to Class I (Full unit class II).  Class III (mesiocclusion/ Pre-normal): when the mesiobuccal cusp of the upper permanent first molar at least one cusp width distal to Class I (Full unit Class III). Some modification has been added like:  Class II subdivision: when there is a Cl1 on one side and Cl2 on the other side  Class III subdivision: when there is a Cl1 on one side and Cl3 on the other side  1/2, 1/3, 1/4 unit Class II and Class III are also used now.
  • 8. Mohammed Almuzian, University of Glasgow 7 Advantage  Simple  Widely accepted  Reliable and reproducible Drawbacks  Cannot used in primary dentition  Not distinguish between dental and skeletal problems  Only consider problem in AP direction  Consider the 6s as fixed point which are not in reality and can be affected by environmental factors.  Cannot used when 6s extracted Incisor classification By British standard institutes (1983)  It is based on the relationship between the lower incisor edges and the upper central incisors’ cingulum plateau.  According to the definition of these classes as follows: A. Class I: the lower incisor edges occlude with or lie immediately below the cingulum plateau of the upper incisors. B. Class II: the lower incisor edges occlude or lie posterior to the cingulum plateau of the upper incisors. Two divisions of this class were described:  Division 1: the upper incisors are proclined with an increased overjet.  Division 2: all the upper incisors or just the centrals are retroclined. The laterals may be proclined. The overjet is decreased but may be increased. C. Class III: the lower incisor edges occlude or lie anterior to the cingulum plateau of the upper incisors. Overjet is usually reduced or reversed.
  • 9. Mohammed Almuzian, University of Glasgow 8 Some modification has been added like:  Class II subdivision: one incisor in CLII and other side CLI  Class II indefinite when one incisor retroclined and the other is proclined (Gravely)  Class II intermediate when the incisor retroclined or upright and the OJ 5-7 mm (Stephen and William, 1993). Skeletalclassification 1. Skeletal classification is obtained from lateral cephalometric radiograph to support the clinical findings. 2. Three skeletal classes were described using cephalometric points and angular measurements:  Class I: lower dental base is related to the upper dental base (ANB= 2- 4˚).  Class II: lower dental base is retruded relative to the upper dental base (ANB> 4˚)  Class III: lower dental base is protruded relative to the upper dental base (ANB <2˚).  Wits appraisal and Balllard conversion can be used in a similar way to ANB. Index of Orthodontic Treatment Need  This was developed by Brooke and Shaw in 1989.  Specific ruler had been developed to make the procedure easy.  IOTN in general is composed of two components:
  • 10. Mohammed Almuzian, University of Glasgow 9 1. The aesthetic component a) This was developed by Evans and Shaw (1987). It was originally called the SCAN (Standardised Continuum of Aesthetic Need). A lay panel was used. b) It is a ranking system (1-10) using coloured photographs which can be said to assess dental attractiveness. c) Number 1 is the most attractive while number 10 is the least attractive. Rating is allocated to the clinician and sometime to the patient for overall attractiveness compared with the photo and not specific morphological similarity to the photo. d) The NHS does recognise that some children need and benefit from orthodontic treatment on the basis of poor aesthetics. The Aesthetic Component of the IOTN is a scale of 10 colour photographs showing different levels of dental attractiveness. The grading is made by the orthodontist matching the patient to these photographs. The photographs were arranged in order by a panel of lay persons. e) Within the NHS if a patient in Dental Health category 3 has an Aesthetic Component rating of 6 or more NHS treatment is permissible. f) Monochromic photographs are used for dental cast assessments. g) It has been reported that monochromic photographs have advantage that raters are not influenced by oral hygiene, gingival condition, or poor colour matching in anterior restorations . the black and white is used to rate the SM. (Woolass and Shaw, 1987). Treatment priority and need according to AC 1. Grades 1 - 3 No/slight need for treatment 2. Grades 4 mild 3. Grades 5 6 7 borderline need for treatment
  • 11. Mohammed Almuzian, University of Glasgow 10 4. Grades 8 9 10 Definite need for orthodontic treatment 2. The dental health component a) This was developed based on the index used by the Swedish Dental Board. It consists of 14 qualifiers and 5 grades, grade 1 representing little or no need for treatment and grade 5 representing great need of treatment. Ruler is used for measurement. b) It assesses few points in order as follows (MOCDO): Missing teeth, Overjets, Crossbites, Displacements, and Overbites. c) Only the highest scoring trait need be recorded, as this determine the grading for the patient. Treatment priority and need according to DHC 1. Grades 1 & 2 No need for orthodontic treatment 2. Grade 3 Borderline need for treatment 3. Grades 4 & 5 Definite need for treatment Advantages 1. Valid 2. Reproducible 3. Acceptable to clinician
  • 12. Mohammed Almuzian, University of Glasgow 11 4. Easy and quick to apply 5. Can be used directly on patients or on dental casts 6. Yield quantitative data which can be analyzed. Disadvantages: 1. Crowding represented a problem in recording when the patient is in the mixed dentition. 2. The AC has no side view rating or class III malocclusion. 3. Objective index 4. No representation of aesthetic or skeletal relationship 5. No assessment of crowding which relies on displacement only NB:  Complexity can be defined as "intricate or complicated".  Difficulty is defined as "needing much effort and skill"  Severity is how far a malocclusion deviates from normal. Reproducibility of the IOTN: 1. Dental Health Component  In the study of Brook and Shaw in 1989 they have shown that the reproducibility of this component is very good.  They also found that the common trait causing disagreement in descending order of frequency were; crowding, increased overjet, crossbites, and overbites.
  • 13. Mohammed Almuzian, University of Glasgow 12 2. Aesthetic Component:  High level of agreement found between patients, parents and orthodontists when grading a patient (Evans and Shaw, 1987).  This was supported with the results that suggested that the correlation coefficients of this component were reasonably high (Brook and Shaw, 1989).
  • 14. Mohammed Almuzian, University of Glasgow 13 In order to memorize them use this acronym 1) Grade 1=D 2) Grade 2= ABCDEFG 3) Grade 3= ABCDEF 4) Grade 4= ABCDEF+LHM+TX 5) Grade= SIMPHA Missing teeth (5.i, 5.h or 4.h) Missing teeth relates to: impacted, impeded eruption, hypodontia. Impeded eruption (5.i)  If a tooth is out of the line of the arch and erupted it would be considered (ectopic)  The tooth is considered impeded or impacted if the spaceremaining for an erupted tooth is less than or equal to 4mm and the angulation is not favorable (horizontal directed not vertical)  In the mixed dentition, the distance from the mesial contact point of the first permanent molar to distal contactpoint of the lateral incisor is less than 18 mm or 17 mm in the upper and lower dental arches respectively, then the canine is considered impacted. Hypodontia (5.h or 4.h)  Where there is extensive hypodontia (more than one tooth missing in each quadrant) requiring either space closure or pre-restorative orthodontics the grade would be 5h.  When there is only one tooth missing per quadrant the scorewould be 4h  Hypodontia is counted if the spacewill be address orthodontically (open or close not to accept)
  • 15. Mohammed Almuzian, University of Glasgow 14 Overjet (2.a, 3.a, 4.a, 5.a, 2b, 3b, 4b, 4m,5m) The overjet  It is measured using the ruler held parallel to the occlusal plane and radial to the line of the arch  The overjet is recorded to the labial aspect of the incisal edge of the most prominent incisor (lateral or central incisors). If the incisor falls on the ruler line the lower grade is allocated. A reverse overjet  It is recorded when ALL four incisors are in lingual occlusion.  If the reverse overjet is greater than 1 mm it is important to investigate whether the individual has masticatory or speech (M&S) difficulties.  There are several methods of investigation but a simple approachis to ask the individual to count from 60-70 noting any difficulty in pronunciation. In addition, any signs and symptoms of mandibular dysfunction should be checked. Crossbite (2.c, 3.c, 4.c)  An anterior crossbite is when 1, 2 or 3 incisors (BUT) not all of them are in lingual occlusion.  A posteriorcrossbite is recorded when the posterior tooth or teeth are cusp to cusp or in full crossbitein a buccal or lingual perspective.
  • 16. Mohammed Almuzian, University of Glasgow 15  The grade recorded depends on the severity of discrepancy between retruded contactposition (RCP) and intercuspal position (IP).  The greater the discrepancy between RCP an IP, the higher the grade  Scissorbite always has a grade of 4L Displacementof contactpoints (2.d, 3.d, 4.d) The contactpoint displacement is measured between anatomical contact points where teeth deviate from the line of the arch. Only the worst displacement is recorded  Vertical displacements from the occlusal plane are not recorded.  Spacing is not generally recorded in the Dental Health Component. But if spacing is associated with a tooth or teeth deviating from the line of the arch, the contact point displacement is recorded.  Displacements between deciduous and permanent teeth are not recorded.  Contact point displacements due to rotated teeth (generally lower 2nd premolars) are not recorded.  However, if the rotation results in a discrepancy between retruded contact position (RCP)and intercuspal position (IP) as a direct result of occlusal interference then a crossbite is recorded according to the severity of the discrepancy between IP and RCP.
  • 17. Mohammed Almuzian, University of Glasgow 16 Overbite and Open bite (2.e/f, 3.e/f, 4.e/f)  Overbite and open bite relates to any of the lateral or central incisors.  The largest vertical discrepancy is recorded.  It is also important to note if there is any gingival or palatal trauma as a result of the deep overbite Other like acronym GTSXas below Buccalocclusion(2.g) The buccalocclusion is assessed irrespective whether the teeth interdigitate in Angle's Class I, II or III. Submerging teeth (5.S) Submerging teeth are not generally recorded unless only two cusps remain visible and/or the adjacent teeth are severely tipped towards each other and closely approximated.
  • 18. Mohammed Almuzian, University of Glasgow 17 Tipped teeth (4.t) When a tooth has erupted and is tipped against an adjacent tooth, resulting in food packing it may require orthodontic treatment to upright and level to eliminate the problem Supernumerary teeth (4.x) It is graded ONLY if a supernumerary tooth requires extraction followed by orthodontic alignment and/or spaceclosure PEER ASSESSMENTRATING (PAR)  This index was developed by Richmond et al. (1992). It was formulated over a series of six meetings in 1987 with a group of 10 experienced orthodontists.  This index was developed to record the malocclusion at any stage of treatment.  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.  Study models used with a specifically designed ruler for this index. The ruler has all the information summarized which makes measurement quick and easy to perform.  The score zero indicates good alignment and higher scores (rarely beyond 50) indicates increased levels of irregularity.  The difference between the pretreatment and posttreatment scores represent the degree of improvement as a result of orthodontic intervention and active treatment.
  • 19. Mohammed Almuzian, University of Glasgow 18  There are 11 components of the PAR index: 1. Upper anterior segment 2. Lower anterior segment 3. Upper right segment 4. Upper left segment 5. Lower right segment 6. Lower left segment 7. Right buccal occlusion 8. Left buccal occlusion 9. Overjet 10.Overbite 11.Centrelines  Each dental arch is divided into three recording segments left and right buccal segments and the anterior segments. Reliability It has been reported that the PAR index has an excellent reliability within intra and inter-examiner agreement (Richmond et al., 1992). Buccaland anterior segments o Buccal segments start from the mesial anatomical contact point of the first permanent molar to the distal anatomical contact point of the canine. o Anterior segments starts from the mesial anatomical contact point of the canine on one side to the mesial anatomical contact point of the canine on the opposite side. o The occlusal features recorded are crowding, spacing, and impacted teeth. o Displacements are recorded at the shortest distance between contact points of adjacent teeth parallel to the occlusal plane with the exception of the displacements that are present between the first, second and third
  • 20. Mohammed Almuzian, University of Glasgow 19 molars. This is because of the fact that the contact points are very broad and are extremely variable within the normal range. o In case of potential crowding in the mixed dentition, average mesio-distal widths are used to calculate the space deficiency. Impacted teeth are recorded when the space available for the tooth is equal or less than 4 mm. o Displaced contact points due to poor restoration are not recorded and the same for contact points between deciduous teeth. o Orthodontic extraction spaces are not recorded o Spacing in the anterior segment resulting from extraction, agenesis or avulsion of incisors or cuspids is recorded as follows: - If closing spacethe spaceis recorded - If opening space and restore it, the spaceis not recorded unless it is less than or equal to 4 mm PAR Score Amount of teeth displacement 0 0 mm – 1mm 1 1.1 mm – 2mm 2 2.1 mm – 4mm 3 4.1 mm- 8mm 4 Greater than 8mm 5 Impacted teeth Mixed dentition crowding assessment using average mesio- distal width Upper Canine 8mm Total 22mm Impaction < = 18mm1st 7mm
  • 21. Mohammed Almuzian, University of Glasgow 20 Premolar 2nd Premolar 7mm Lower Canine 7mm Total 21mm Impaction < = 17mm1st Premolar 7mm 2nd Premolar 7mm Buccalocclusion oThis is recorded for both right and left sides in occlusion in three dimensions. A-P, vertical and transverse. oThe recorded zone is from the canine and to the last molar whether this was the first, second or third molar. oTemporary developmental stages and submerging deciduous teeth are excluded. PAR Score Buccal Occlusion discrepancy Vertical 0 No discrepancy in intercuspation 1 Lateral open bite on at least 2 teeth greater than 2 mm Antero-posterio 0 Good interdigitation (Cl I, Cl II or Cl III)
  • 22. Mohammed Almuzian, University of Glasgow 21 1 Less than ½ unit discrepancy 2 ½ a unit discrepancy (cusp to cusp) or more Transverse 0 No crossbites 1 Crossbite tendency 2 Single tooth in crossbite 3 More than 1 tooth in crossbite 4 More than 1 tooth in scissor bite Overjets o The recording zone starts from the distal anatomical contact point of the lateral incisor on one side to the distal anatomical contact point of the lateral incisor on the other side. o The most prominent aspect of any one incisor is recorded with a ruler held parallel to the occlusal plane. o Overjets and crossbites are recorded here. The sum of the two scores is the total score for this component. If there is a positive overjet and incisors or canines in crossbite the scores should be added together Overjet component measurements Overjet 0 0-3 mm 1 3.1- 5mm 2 5.1- 7mm 3 7.1- 9mm 4 Greater than 9mm
  • 23. Mohammed Almuzian, University of Glasgow 22 Anterior crossbites 0 No discrepancy 1 One or more teeth edge to edge 2 One single tooth in crossbite 3 Two teeth in crossbite 4 More than two teeth in crossbite Overbite oThe vertical overlap or open bite of the anterior teeth is recorded. oThe tooth with the greatest overlap is recorded. oIf OB and AOB are present, then they should be added. Overbite component measurements Open bite 0 No open bite 1 Openbite less than and equal to 1mm 2 Openbite 1.1 mm – 2 mm 3 Openbite 2.1 mm- 3 mm 4 Open bite greater than or equal 4mm Overbite 0 Less than or equal to 1/3 coverage of the lower incisor 1 Greater than 1/3, but less than 2/3 coverage of the lower incisor
  • 24. Mohammed Almuzian, University of Glasgow 23 2 Greater than 2/3 coverage of the lower incisor 3 Greater than or equal to full tooth coverage. Centrelines o Records the centreline discrepancy in relation to the lower central incisor. o If a lower incisor has been extracted the measurement is not recorded. PAR Score Centrelines discrepancyassessment 0 Coincident and up to ¼ lower incisor width 1 ¼ to ½ lower incisor width 2 Greater than ½ lower incisor width Advantages 1) Reliable. 2) Easy and quick considering the PAR ruler is used. 3) May be used for all types of malocclusion, treatment modalities, and extraction / non-extraction cases. 4) The score provides an estimate of how far a case deviates from the normal 5) Good tool in measuring the perceived degree of improvement and therefore the success of treatment. Thus, it is an indicator for clinical performance NB: OJ multiplied by 6, OB by 2 and ML by 4, Zero weighing for displacements Disadvantages 1. It is not an index of treatment need.
  • 25. Mohammed Almuzian, University of Glasgow 24 2. It provides a single summary score for all the occlusal anomalies. Thus, it is insensitive and can misjudge individual patient need. Therefore, it is better to weigh each malocclusion individually. 3. The reliability of the upper left and right segments was found to be low and this was referred to the fact that the upper teeth varies in size. The larger teeth cause a broader contact points which makes inaccurate recording of the scores (Richmond et al. 1992). 4. Hamdan and Rock (1999) suggested the limitation of PAR index to be:  Overjet high weighing  Overbite low weighing Outcome assessment There are basically three methods of assessing outcome using the PAR Index. o The first is to record the reduction in PAR score. 22 point reduction indicates great improvement. o The second method is to calculate the percentage change. A percentage improvement of greater than 70% can be considered as a good standard of orthodontic treatment. While, 30-70% reduction represents an improvement. Less than 30% reduction is either considered as becoming worse or no improvement. o The final method of assessmentis to use the graph (nomogram)
  • 26. Mohammed Almuzian, University of Glasgow 25 INDEX OF COMPLEXITY, OUTCOME AND NEED (ICON)  This is the first index based on an international orthodontic opinion.  This index comprised of an assessment of: Score 0 1 2 3 4 5 1) Aesthetic 1-10 as judged using IOTN AC 2) Upper arch crowding Only the highest trait either spacing or crowding Less than 2mm 2.1- 5mm 5.1- 9mm 9.1- 13mm 13.1- 17m m More than 17mm or impacte d teeth 3) Upper spacing Up to 2mm 2.1- 5mm 5.1- 9mm More than 9mm 4) Crossbite Transverse relationship of cusp to cusp or worse No crossbites Cross bite present 5) Incisor open bite Only the highest trait either openbite or overbite Complete bite Less than 1mm 1.1- 2mm 2.1- 4mm More than 4mm 6) Incisor overbite Lower incisor coverage Up to 1/3 tooth 1/3- 2/3 coverag e 2/3 up to full covered Fully covere d
  • 27. Mohammed Almuzian, University of Glasgow 26 7) Buccal segment anterioposterior Left and right added together Cusp to embrasure relationshi p only, Cl I, II, III Any cusp relation up to but not includin g cusp to cusp Cusp to cusp relation ship ABO DiscrepancyIndex (ABO DI) The elements which make up the ABO Discrepancy Index are measurements of:
  • 28. Mohammed Almuzian, University of Glasgow 27 1. Overjet and anterior cross bite 2. overbite and anterior open bite and lateral open bite, 3. crowding, 4. buccalocclusion, 5. lingual posterior crossbite and buccal posterior crossbite, 6. ANB angle and SN-Go-Gnand lower incisor to GoGnangle. 7. An additional category designated "other" is available so that other conditions which may affect or add to complexity of treatment may be scored. OVERJET:Overjet is scored as the distance between the incisal edge of the most forward positioned maxillary incisor and the most forward positioned mandibular incisor. For overjets of 0 mm. (edge to edge), 1 point is scored;for overjets of 0 to 3 mm., no points are scored;for 3.1 - 5 mm., 2 points are scored;for 5.1 - 7 mm., 3 points are scored;for 7.1 - 9 mm., 4 points are scored and if over 9 mm., 5 points are scored. If there is a negative overjet (anterior crossbite), the scoreis recorded as 1 point per mm. per anterior tooth in crossbite. OVERBITE:For overbites of up to 3 mm. no points are scored. If the overbite is between 3.1 to 5 mm. 2 points are scored;if between 5.1 to 7 mm. 3 points are scored. If the lower incisors are impinging on the palatal tissue (100% overbite), then 5 points are scored. ANTERIOR OPEN BITE:If the maxillary and mandibular incisors are in an edge to edge relationship (overbite = 0), then 1 point is scored. For each millimeter of open bite, 2 points are scored for each maxillary tooth involved from canine to canine. No points are scored for the maxillary canines if they are blocked out of the arch to the labial.
  • 29. Mohammed Almuzian, University of Glasgow 28 LATERAL OPEN BITE:For each maxillary tooth (from the first premolar to third molar) in an open bite relationship with the lower arch, 2 points are scored per mm. of open bite for each tooth. CROWDING:When scoring crowding, the most crowded dental arch is considered. From 1 to 3 mm. one point is scored;from 3.1 - 5 mm. 2 points are scored;from 5.1 - 7 mm. 4 points are scored. If the crowding is greater than 7 mm. 7 points are scored. OCCLUSION:When scoring occlusion, the Angle classification is used. If the mesiobuccal cusp of the maxillary first molar occludes with the buccalgroove of the mandibular first molar or anywhere between the buccalgroove and the mesiobuccal cusp (cusp to cusp or end on), no points are scored. If the occlusal relationship is end on (cusp to cusp) class II or III, then 2 points are scored per side. If the relationship is a full class II or III, then 4 points are scored per side. If the relationship is greater or beyond class II or III, then 1 additional point is scored per mm. for each side. LINGUAL POSTERIOR CROSSBITE:For each maxillary posterior tooth in lingual crossbite(from the first premolar to the third molar), 1 point is scored. BUCCAL POSTERIOR CROSSBITE:For each maxillary posterior tooth (from the first premolar to the third molar) in complete buccal crossbite, 2 points are scored. CEPHALOMETRICS:If the ANB angle is greater than 5.5 degrees or less than -1.5 degrees, 4 points are scored. Foreach additional degree above or below these values, an additional point is scored.
  • 30. Mohammed Almuzian, University of Glasgow 29 If the SN-Go-Gnangle is between 27 and 37 degrees, zero points are scored. If the SN-Go-Gnangle is greater than 37 degrees, then 2 points are scored for each additional degree above 37. If the SN-Go-Gnangle is less than 27 degrees, then 1 point is scored for each additional degree below 27. If the lower incisor to GoGn angle is greater than 98 degrees, then 1 point is scored for each additional degree above 98. OTHER:At the discretion of the examiner an additional 2 points may be awarded for each of the following conditions:  Missing teeth (except for third molars)  Supernumerary teeth  Impactions (except for third molars)  Ectopic eruption  Anomalies of tooth size and shape  Dental midline discrepancies greater than 3 mm.  Skeletal asymmetries (involving dental compensation for case completion) Disadvantagesof ABO DI  Complicated  Time consuming  Relies on cephs, expensive, time consuming, irradiation, reproducibility  Reproducibility Advantages of ABO DI o Detailed/comprehensive
  • 31. Mohammed Almuzian, University of Glasgow 30 o Measures case complexity-link this to who should treat the case, and case suitability for examinations, remember that difficulty is elusive and subjective.
  • 32. Mohammed Almuzian, University of Glasgow 31 HANDICAPPING MALOCCLUSION ASSESSMENT RECORD (HMAR)  The purpose of the HMAR form is to provide a means for establishing priority for treatment dentofacial deformity constitute a hazard to the maintenance of oral health and interfere with the well-being of the child by adversely affecting dentofacial aesthetics, mandibular function or speech (Salzmann, 1968).  The HMAR is used to:  Inter and intra-arch relationships are looked at. 1. Intra-arch deviations include:  Missing teeth  Crowding  Rotations  Spacing 2. Inter-arch relationships include:  Overjet  Crossbite  Overbite  Openbite  Molar and canine relationships IRREGULARITY INDEX  Developed by Little (1975).  It assess the irregularity of the lower labial segment by measuring the linear displacement of the contact points in mm (from the mesial contact point of the canine on one side to the mesial contact point of the canine on the other hand side)
  • 33. Mohammed Almuzian, University of Glasgow 32  The sum of these 5 displacments representing the relative degree of anterior irregularity. Crowding index In occlusal view, the CI was determined by measuring the available horizontal space parallel to the occlusal plane, between the least displaced interproximal contact points. The actual width of the corresponding tooth was then deducted from the available spaceto give a resultant amount of crowding (positive measure) or spacing (negative measure) for each tooth The validity of maxillary expansion indices, O'Reilly, 1995 1) In 1909, Pont (overestimate)described a method which assumed a constant relationship between the sum of the maxillary incisor widths (SI=Sum of Incisors) and the width of the dental arch in an ideal uncrowded dentition. The formula was then transposed to allow arch width prediction: Required inter-premolar width = SI/ 0.80 Required inter-molar width = SI/0.6 2) McNamara (overestimate)proposed asimple rule of thumb indicating an ideal average Intermolar width in males of 37 mm and in females of 36 mm
  • 34. Mohammed Almuzian, University of Glasgow 33 3) Schwarz's analysis (accurate)was calculated with the appropriate formula as described by Schwarz. In narrow faces, the first inter-premolar width is SI + 6 mm while the intermolar width is SI + 12 mm; in the average face the widths are SI + 7 mm and SI + 14 mm; in broad faces they are SI + 8 mm and SI + 16 mm respectively. A treatment difficulty index for unerupted maxillary canines, Pitt, Hamdan and Rock, 2006 The prognosis for alignment of an impacted maxillary canine is affected by several factors (McSherry, 1996): 1. Horizontal position 2. Age of patient. 3. Vertical height. 4. Bucco-palatal position. 5. Angulation to midline. 6. Rotation. 7. Coincidence of arch midlines. 8. Alignment and spacing of the upper labial segment. 9. Condition of primary canine. 10. Missing teeth. Result of this study, Difficulty scorein order: (ACRONYM HAV BARMA CM) Plaque index  Records levels of supragingival plaque present  Subjective scoring: o 0= no plaque at gingival margin o 1= initial deposite of plaque at gingival margin (not visible to the eye)
  • 35. Mohammed Almuzian, University of Glasgow 34 o 2= plaque at the gingival margin (visible to the eye) o 3= heavy plaque accumulation on tooth Gingival index o 0= healthy o 1= mild inflammation, slight change in colour. o 2= moderate inflammation, redness, moderate glazing, bleeding on pressure. o 3= severe inflammation, redness, hyperplasia, tendency for spontaneous bleeding.  Recommends scoring of 6 teeth which are: 6 2 | 4 4 | 2 6  Four values per tooth recorded;buccal, lingual, mesial and distal. Further reading if you like the indecis!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!! • HANDICAPPING LABIO-LINGUAL DEVIATION (HLD) • SWEDISH INDEX (NEED FOR TREATMENT INDEX) • TREATMENT PRIORITY INDEX (TPI)