The Irregularity Index: A quantitative

score of mandibular anterior aZignment

Robert M. little,
Seattle, Wash.

D.D.S., M.S.D., Ph.D.*

nterior dental crowding is perhaps the most frequently

occurring
characteristic of malocclusion; yet the term crowding is one of the most ambiguous terms in the dental vocabulary. Patients, parents, the public, and the profession are unquestionably
aware of and concerned with dental crowding and
avidly seek its correction. Terms such as dental irregularity,
overlap, and crowd&g are subjective, nonquantitative,
even emotional terms which can represent
a diversity of clinical meaning. Adjectives such as mild, moderate, severe, significant, etc. are descriptively helpful but still allow a wide range of interpretation.
An index or score of incisor crowding would be helpful in many respects.
Public health and insurance programs are becoming increasingly interested in
indices used to establish malocclusion severity as a guide in determining treatment priorities. Epidemiologic
studies comparing the presence and amount of
various characteristics of occlusion would benefit from a quantitative measure of
the severity of dental irregularity.
An index would be valuable in assessing the
degree of initial malrelationship
as well as in comparing initial crowding with
posttreatment and postretention results.
Evidence of progressive instability is often first noted by progressive crowding of mandibular incisors following removal of retaining devices. Whatever the
multiplicity
of causes for relapse, mandibular
incisor irregularity
is often the
precursor of maxillary crowding, deepening of the overbite, and generalized
deterioration of the treated case, Since the status of the six mandibular anterior
teeth seems to be a limiting factor in treatment and stability, it would seem
logical to develop a diagnostic index that would accurately reflect the mandibular
anterior condition.
Numerical indices have been developed to rank or score the severity of malocclusion relative to a preconceived orthodontic normal or ideal. Several malAssistant
of Washington.

554

Professor,

Department

of

Orthodontics,

School

of

Dentistry,

University

Volume
68
Num her 5

Irregularity

Index

555

occlusion indices are in current use, including the HLD Tndex,l the Treatment
Pri0rit.y Index,2 the Index of the American Association of Orthodontists,3 the
Gcclusal Index,4 and the Ackerman-Proffit
Rating Scale.5 The difficulties of
identifying
normal alignment and normal occlusion from a purely physiologic
point of view, plus the complexities of defining measurements which are truly
indicative of malrelationship, are added to the problem of consistency of evaluation among examiners.
Several methods of assessing incisor crowding have been proposed. Barrow
and White6 described crowding in terms of fractions of permanent central incisor width. For example, mandibular crowding of a given case could be described as one third of a lower central incisor for a mild crowding situation
while four thirds or more would describe crowding of a more severe nature.
Moorrees and Reed7 stated that crowding could be visualized as the numerical
difference between mesiodistal crown width and the space available-an
arch
length assessment rather than a crowding index.
Van Kirk and Pennel* suggested a numerical but not a truly quantitative
scoring method, with ideal alignment scored zero, less that 45 degrees of incisor
rotation or less than 1.5 mm. of incisor displacement scored 1, and greater than
45 degrees of rotation or greater than 1.5 mm. of displacement scored 2.
Grainge9 employed the same method in the TPI. Bjijrk and colleagues3 modified
the Van Kirk method slightly by using 15 degrees as the division between normal and crowded incisors; in this method, crowding was further assessed by
recording incisors which are deviated from the midline of the alveolar process
by more than 2 mm. Summers4 used a method similar to that of Van Kirk,
scoring 1 for cases demonstrating 1.5 to 2.0 mm. of incisor deviation or 35 to 45
degrees of rotation from normal arch alignment and 2 for greater than 2.0 mm.
of displacement or greater than 45 degrees of rotation from normal arch form.
In Drakers HLD Index,l crowding or labiolingual
spread is defined as
the deviation of each incisor, in millimeters, from a normal arch. Salzmanns
AA0 Index3 subjectively scored crowding for each tooth as either present or
absent, with no distinction made between varying amounts of crowding. Proffit
and Ackerman5 described a subjective means of assessing crowding which involved the rating of severity on a scale from 0 to 5. It is apparent that, thus far,
no true quantitative measure of the amount of incisor irregularity has yet been
proposed in the literature.
Carlos suggests that any index which is to be used for the study of a disease or condition must stand the tests of validity and reliability. To be valid,
a test must actually measure what it proposes to measure. Carlos stated that one
method of assessing an index, which represents a score of severity, is to obtain
index scores and independently compare them with subjective clinical ranking
of severity on a scale of measurement. Computation of the correlation between
clinical and index scores would statistically demonstrate index validity.
Reliability
(also known as reproducibility
or precision) is concerned with
the degree of consistency between results of different examiners or the same
examiner on different occasions. Several studies have dealt with the reliability
of index scores.11-14For example, Popovich and Thompson14 found an association

556

Little

Fig. 1. Technique
adjacent
anatomic
ments
representing

involves
measuring
the linear
contact
point
of mandibular
the Irregularity
Index.

distance
anterior

from
teeth,

anatomic
the sum

contact
of five

point
to
measure-

between intraexaminer
variat.ion and the degree of malocclusion being assessed,
noting greater error in Graingers index at the low and medium severity levels
than at the higher scores.
The

irregularity

Index

The proposed scoring method involves measuring the linear displacement of

the anatomic contact points (as distinguished from the clinical contact points)
of each mandibular incisor from the adjacent tooth anatomic. point, the sum of
these five displacements representing the relative degree of anterior irregularity
(Fig. 1). Perfect alignment from the mesial aspect of the left canine to the
mesial aspect of the right canine would theoretically have a score of 0, with increased crowding represented by greater displacement and, therefore, a higher
index score. Rather than measuring from contact point to ideal arch form or to
another subjective point, the actual linear distance between adjacent contact
points is determined. Such a measure represents the dist,ance that anatomic contact points must be moved to gain anterior alignment.
As suggested by Peck and Peck,l: measurements are obtained with a dial
caliper calibrated to at least tenths of a millimeter. The dial caliper is easier to
read and is more precise than the Vernier caliper, where accuracy to 0.1 mm. is
important.
The caliper points should be sharpened to a fine edge to permit access and make accurate measurements possible.
Each of the five measurements is obtained directly from t,he mandibular cast
rather than intraorally,
since proper positioning of the caliper is essential for
consistent accuracy. The mandibular cast is viewed from above, sighting down

Volume
Number

68
5

Figs. 2 awl
3. Calipers
should
be held
horizontal
linear
displacement
of anatomic

Irregularity

parallel
contact

to the
points.

occlusal

plane,

Index

measuring

557

only

onto the incisal edges of the anterior teeth, the caliper held parallel to the occlusal plane while the beaks are lined up with the contact points to be measured
(Figs. 2 and 3). Each of the five measurements represents a horizontal linear
distance between the vertical projection of the anatomic contact points of adjacent teeth. Although contact points of anterior teeth can vary in the vertical
plane, correction of vertical displacement will not appreciably affect anterior
arch length; therefore, all vertical discrepancies of contact points must be disregarded. It is then important for the evaluator to hold the caliper consistently
parallel to the occlusal plane while obtaining each measurement, thereby ensuring the recording of only horizontal displacement.

558

Am. J. Orthod.
November
191.5

Little

Fig. 4. Irregularity

Index

of four

cases

representing

varying

degrees

of crowding.

As illustrated in Fig. 4, rotations and labiolingual displacement are often

accompanied by varying amounts of mesiodistal overlap of contact points. The
caliper beaks must be aligned in such a way as to measure from contact point
to contact point rather than only in a purely labiolingual direction. It is suggested that mesiodistal spacing be disregarded, provided the teeth in question

Volume
Number

68
5

Irregularity

Fig.

4 (Contd).

For legend,

see opposite

Index

559

page.

are : in proper arch form; if spacing as well as displacement or rotations is not 4

on1y the labiolingual displacement from proper arch form is recorded. Althou -&
an argument could be made for the treatment of spacing as a negative value in
in this study it was determined that subtracting spa4 .ng
an1;erior irregularity,
distort the meaning of the irreg P
val ues from the total would inappropriately

560

Little

larity index-a
value intended
relative to anterior arch form.
Materials

and

to represent

crowding

or deviation

of teeth

methods

In phase 1 of this study, seven orthodontists with varying backgrounds and

clinical experience evaluated the anterior irregularity
present in fift,y casts
selected to represent a wide range of crowding. Each cast was subjectively
ranked on a scale ranging from 0 to 10, using the following criteria:
0 Perfect alignment
l-3 Minimal irregularity
4-6 Moderate irregularity
7-9 Severe irregularity
10 Very severe irregularity
In Phase 2 of the study, five of these same orthodontists used the proposed
Irregularity
Index to determine quantitatively
the index scores of twenty-five
of these same mandibular
casts. The examiners determined the irregularity
scores on two separate occasions, at least 1 month apart and at least 1 month
after subjectively assessing irregularity.
There were, therefore, ten (2 x 5)
severity estimates available for every cast.
The data were analyzed with the intent of assessing the validity and reliability of the proposed irregularity
index using the following analyses:
1. Subjective score interexaminer
variability was examined by means of
a two-way analysis of variance, marginal means and the Friedman
analysis of variance.
2. Irregularity
index intraexaminer
variability was evaluated with paired
t tests to note any difference between the first- and second-hand scores
and binomial tests to check for a tendency to score higher or lower on
the second trial.
3. Irregular
index interexaminer
variability was evaluated by means of
a two-way analysis of variance and marginal means.
4. VaZidity was assessed by means of a linear regression comparing
average index scores with subjective scores.
Results

Subjective score interexnminer

variability. The two-way analysis of variance
comparing seven examiners on fifty casts rejected the null hypothesis (p < 0.01)
that all the judges rated the casts the same on a subjective scale of crowding.
Orthodontists seem to differ in their individual subjective assessment of severity
of mandibular anterior crowding. Evaluation of marginal means, that is, each
examiners mean subjective score, indicat,ed that four of the examiners were
closely grouped in scores (4.16, 4.54, 4.70, 4.78)) two others were close (3.50,
3.80), while one consistently scored lower than all other judges (2.88). The
Friedman analysis of variance, a statistical rank-ordering
test, also indicated
that one person consistently ranked all casts as less severe than all other judges
while groups of two and four examiners ranked the casts similarly.
Irregularity
kdex iwtraexaminer variability. Paired t tests comparing each

Index

Irregularity
INCISOR
Extreme

561

IRREGULARITY

10
f

r = .Sl

Perfect

0-i
0

I
2

I
4

I
6

I
8

Irregularity

Fig. 5. A scattergram
dibular
anterior
teeth
(r = 0.81).

demonstrating
as assessed

the degree
subjectively

I
IO

,
12

1
14

,
16

I
IS

index

of association
and by means

between
crowding
of a quantitative

of mantechnique

examiners quantitative measurements of twenty-five casts using the Irregularity

Index demonstrated no significant difference between the two trials for six of
the seven examiners (p < O.Ol), indicating good consistency between first and
second measurements. The mean difference of the scores for the six judges was
less than 0.06 mm., while the seventh judge had a mean difference of 0.41 mm.
The binomial test showed no indication of a tendency to score higher or lower
on the second trial.
Irregularity
Index interexaminer
variability.
The analysis of variance rejected the null hypothesis that all the judges measured the casts the same. The
analysis showed significant interaction between judges and casts ; therefore,
when the main effects of hand measuring (which are a,veraged over all the
casts) were interpreted, extreme caution was in order. Each judges score on
each cast was examined, rather than the average scores, using a Studentized
range test. At p < 0.05 there was a significant difference between the judges
ranks on seven of the twenty-five casts and no significant difference on the remaining eighteen casts, which accounts for the presence of interaction. Examination of marginal means demonstrated t,hat one person measured consistently
lower than all others, having the lowest score twenty-one out of twenty-five
times, while the remaining four examiners were quite close.
Irregularity
index versus subjective score. As illustrated
in Fig. 5, the
Pearson Product-Moment
Correlation Coefficient comparing subjective ranking
of crowding against that quantitative Irregulary
Index score demonstrated a
fairly predictable linear relationship (r = 0.81). This value indicates that approximately 65 per cent of the variation among subjective scores is accounted
for by variation in hand measurements, indicating that the index is a usable
predictor.

562

Little

Discussion

Subject,ive evaluation of mandibular

anterior irregularity
is an u~lreliablc
method of ranking severity, as was evident by the divergence of opinion among
a group of orthodontists when judging the crowding present, in a series of casts.
To minimize the multiple variables which enter into an orthodontic diagnosis
and influence the assessment of case soverity and prognosis, only the mandibular
casts were evaluated, omitting cephalometric films, maxillary casts, facial phot,ographs, and other diagnostic data. Perhaps the orthodontist
rates severity of
crowding by comparison with other similar cases, ease of correction, the skeletalfacial-dental pattern, the long-term prognosis, or other standards based on experience or education. Whatever the guidelines used, subjective assessment of
severity seems to be only moderately consistent, between individuals.
An effective index must be simple to use, must mcasurc what it purports
to measure, and must yield reliable and consistent results. The reliability between trials for six of the seven examiners showed no significant difference between first and second measurements on the same casts (p < 0.01) and no indication of scoring higher or lower on the second t,rial. Interestingly,
the one
judge who showed less consistency was a recent graduate as compared to the
others who had had postgraduate experience of from 3 to 23 years.
Comparison between orthodontists using the Irregularity
Indes showed significant interaction between judges and casts. That is, on certain casts the hand
measurements were not significantly different (eighteen out of twenty-five casts
at p < 0.05), while on others the null hypothesis that the judges ranked the
cases the same (seven out of twenty-five at p < 0.05) was rejected. Again, an
interesting sidelight was that one person consistently ranked the casts as less
severe than all of the other orthodontists (twenty-one out of twenty-five times).
It was later determined that this examiner was incorrectly measuring to an
estimated ideal arch form (Draker) rather than from one contact point directly
to the adjacent contact point.
Index validity was confirmed by the predictive relationship between subjective and hand-measured scores demonstrated by a correlation coefficient of
r = 0.81. Apparently,
there is a predictable linear trend between clinical assessment and the proposed Irregularity
Index.
The Index is not an arch length assessment but, rather, a guide to quantifying mandibular
anterior crowding. Certainly, the method has several flaws,
chief among which is a tendency to assign an unusually high score to cases
involving severe labiolingual displacement of one or more anterior teeth, with
arch length only moderately reduced and treat,ment reasonably simple. Anterior spacing without
rotation and/or labiolingual
displacement would receive no score and must be differentiated from a case demonstrating spacing plus
irregularity
and deviation. In summary, the Irregularity
Index is simple, clinically reliable, and valid but is not without error. The major problem is a tendency to exaggerate cases with considerable irregularity
but little arch length
shortage. The Index does not take into account the patients cephalometric pattern, facial esthetics, age, tooth morphology, the effect of habit correction, etc.-

Volume

68

Number

Irregularity

factors which must be considered in addition

formulating
a comprehensive diagnosis.

Index

563

when one is assessing a case and

Summary

A quantitative
method of assessing mandibular anterior irregularity
is proposed. The technique involves measurement directly from the mandibular cast
with a caliper (calibrated to at least tenths of a millimeter)
held parallel to
the occlusal plane. The linear displacement of the adjacent anatomic contact
points of the mandibular incisors is determined, the sum of the five measurements representing the Irregularity
Index value of the case. Reliability and
validity of the method were tested, with favorable results.
At the University of Washington, several clinical studies ha.ve been and are
continuing to be performed, using this technique as one of several methods 0.f
assessing pretreatment
status and posttreatment
change. It is hoped that this
article will aid the reader in understanding
the rationale and utility of a simple quantitative
tool which could be used in malocclusion assessment.
REHRENCES

1. Draker,
H. : Handicapping
labio-lingual
deviations
: A proposed
index
for Public
Health
purposes,
AM. J. ORTHOD. 46: 295-305,
1960.
2. Grainger,
R.: Orthodontic
Treatment
Priority
Index,
Washington,
1967, National
Center
for Health
Statistics,
Series 2, #25.
3. Salzmann,
J.: Handicapping
malocclusion
assessment
to establish
treatment
priority,
AM.
J. ORTHOD. 54: 749-765,
1968.
4. Summers,
C.:
The
Occlusal
Index:
A system
for
identifying
and
scoring
occlusal
disorders,
AX J. ORTHOD. 59: 552-567,
1971.
5. Proffit,
W., and Ackerman,
J.: Rating
the characteristics
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A systematic
approach
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AM. J. ORTHOD. 64: 258-269,
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6. Barrow,
G., and White,
J.: Developmental
changes
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7. Moorrees,
C., and Reed,
B.:
Biometrics
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8. Van Kirk,
L., and Pennel,
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B.:
A method
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10. Carlos,
J.: Evaluation
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11. Freer,
T., Grewe,
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R. : Agreement
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Angle
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12. Hermanson,
P., and Grewe,
J.:
Examiner
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Angle Orthod.
40: 219-225,
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13. Grewe,
J., and Hagan,
D.: Malocclusion
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AM. J. ORTHOD.
61: 286-294,
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14. Popovich,
F., and Thompson,
G.: A longitudinal
comparison
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Treatment
Priority
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J. Public
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31: 2-8, 1971.
15. Peck,
H., and Peck,
S.: An index
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AM. J. ORTHOD. 61: 384-401,
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lSohoo1 of Dentistry,

University

of Washington

(98195)