British Journal of Orthodontics

ISSN: 0301-228X (Print) (Online) Journal homepage: http://www.tandfonline.com/loi/yjor19

Use of the Index of Orthodontic Treatment Need

(IOTN) in Assessing the Need for Orthodontic
Treatment Pre- and Post-appliance Therapy

S. Richmond, C. T. Roberts & M. Andrews

To cite this article: S. Richmond, C. T. Roberts & M. Andrews (1994) Use of the Index of
Orthodontic Treatment Need (IOTN) in Assessing the Need for Orthodontic Treatment Pre- and
Post-appliance Therapy, British Journal of Orthodontics, 21:2, 175-184, DOI: 10.1179/bjo.21.2.175

To link to this article: http://dx.doi.org/10.1179/bjo.21.2.175

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 Rritish Journal of Orthodontics! Vol. 2/IICJ9.11175-/84

Use of the Index of Orthodontic Treatment

Need (I OTN) in Assessing the Need for
Orthodontic Treatment Pre- and Post-
appliance Therapy
S. RICHMOND, PH.D., M.Sc.D., F.D.S., D.ORTH.
C. T. ROBERTS, M.Sc.
M. ANDREWS, M.Sc.
Unit of Orthodontics, Department of Oral Health and Development, University Dental Hospital of Manchester,
Higher Cambridge Street, Manchester M15 6FH
Accepted for publication January 1993

Abstract. The Index of Orthodontic Treatment Need (IOTN) was used to assess the need for orthodontic
treatment before and after treatment, on a systematic sample of 1225 cases. On the whole, full upper and lower
fixed appliances brought about a greater improvement in Aesthetics and Dental Health Components compared
to other appliance techniques, and were less likely to make the occlusion worse. Jt was found that certain
occlusal traits were more likely to be successfully treated than others. A common problem resulting from
treatment was the development of a cross-bite.
Index words: Orthodontic Treatment Need, Occlusal Indices, Outcome Measures.

Introduction 1983; Haynes, 1979; British Orthodontic Standards

Traditional orthodontic thinking has emphasized the
major benefits of orthodontic treatment on: the 'im-
provement of physical functions, the prevention of
tissue destruction and the correction of aesthetic
impairment' (Standing Dental Advisory Committee,
1973). In times of limited resources it is important
that patients who need treatment should be priori-
tized in order that the most needy should be treated
and that, when treatment is undertaken, the mal-
occlusion should be corrected to an appreciable ex-
tent. Many studies in the U.K. and Scandinavia have
assessed the success of treatment by recording the
various occlusal traits before treatment, and after
treatment.
British studies
Over recent years the standard of orthodontic treat-
ment undertaken within the General Dental Services
has given cause for concern. Several reports have
suggested that British orthodontic results are not as
good as those achieved in North America and
Northern European countries (Cousins, 1973; Shaw,
030t-228X/94/00S000+00$02.00
Working Party, 1986).
A report on child dental health in England and
Wales (Todd and Dodd, 1985) found that 30 per
cent of 15-year-olds who had previously received
orthodontic treatment were in need of further treat-
ment. The Occlusal Index (Summers, 1971) was
used by Elderton and Clark, (1983) to record treat-
ment need in a sample of 256 patients in the Scottish
Dental Service, most of the treatment being under-
taken with removable appliances. Some reduction
was seen in 88 per cent of cases. However, 30 per
cent of cases were minimally improved or made
worse, and in those cases which started with a
marked malocclusion only about one-third showed a
sizeable improvement. Sixty-five per cent of cases
falling in the 'No treatment need' category at the
start of treatment showed a sizeable improvement.
Thirty-five per cent of cases falling in the 'No treat-
ment need' category at the start of treatment showed
no improvement and, in fact, 15 per cent were made
worse.
In a further survey of 51 cases with a class II
division 1 malocclusion treated with removable
appliances (Elderton and Clark, 1984), 41 per cent
© 1994 British Society for the Study of Onhodontics
176 S. Richmond eta/.
of cases finished in the two best categories and sub-
stantial improvement was found for one quarter of
the whole sample. However, 20 per cent of the cases
showed no improvement at all.
In a study undertaken by the Dental Reference
Service in 1984 (DHSS, 1986), for 59 per cent of the
estimate references (852), the dental officer dis-
agreed substantially or fundamentally with the pro-
posed treatment. In 49 per cent of the completed
treatments, the dental officer considered the treat-
ment unsatisfactory to a major or fundamental
extent.
During the year 1986/87, 35 800 orthodontic cases
treated within the General Dental Services were re-
ported as discontinued (14 per cent of all non-prior
approval cases and 26 per cent of prior-approval
cases).
Scandinavian studies
Myrberg and Thilander, (1973a) assessed treatment
results in 1486 cases. In 60 per cent, removable
appliances were used, whilst the remainder were
treated with fixed appliances. In 54 per cent of the
cases the result was good, 37 per cent acceptable,
6 per cent less than good and in 1 per cent treatment
had no effect. However, the criteria for assessing the
success of treatment was not stated.
Berg, (1979) analysed 246 consecutively treated
cases, the majority having undergone fixed appliance
treatment. The author looked at both dental cast
and radiographic records. He found that the object-
ives were only achieved in 43 per cent of all cases.
Root resorption was present in 14 per cent of all
cases and overjet was not eliminated in 13 per cent
of Class II cases. The objectives were not achieved
in a substantial percentage of Class I, Class II, and
Class III malocclusions. Although all the objectives
had not been attained, substantial improvement had
been achieved and the author coined the phrase
'partial success'.
In a further study, Berg and Fredlund, (1981)
used the Treatment Priority Index, TPI (Grainger,
1967) on 60 cases randomly selected from 329 con-
secutively treated patients in two private practices.
At the end of treatment 36 cases (60 per cent)
achieved normal or near normal occlusion. They
found the greater reduction in the TPI score resulted
from an improvement in overjet. It was suggested
that the degree of improvement was more important
than the 'success' of treatment.
Post-retention surveys
There have been several investigations involving the
prevalence of malocclusions over 20 years of age
BJO Vol. 21 No.2
(Ingervall eta/., 1978; Mohlin, 1982; Bernhold and
Lindquist, 1981). These studies indicate that the pre-
valence of malocclusion in men and women is similar
to that found in children, although 10 per cent of
men and 25 per cent of women had previously re-
ceived orthodontic treatment. Mohlin suggested that
the need was still high as much of the orthodontic
treatment was provided 20-30 years ago, probably
as a compromise owing to limited orthodontic re-
sources, removable appliances having been used in
two-thirds of the treatments. The treatments had
probably reduced the severity of malocclusions, but
had not eliminated them. However, Myrberg and
Thilander, (1973b) have reported mild to severe
relapse in 24 per cent of orthodontically treated
children, 1-5 years after treatment.
The long-term stability of orthodontic treatment
has been reported for a group of 96 patients treated
12-35 years previously (Sadowsky and Sakols,
1982), the majority of cases having been treated with
both upper and lower Edgewise appliances. The
authors revealed that 72 per cent of cases still had
deviations outside the 'ideal' range. There was a
tendency for overjet and overbite to increase, as
well as for the development of lower anterior crowd-
ing.
Other studies have shown that even when optimal
treatment results had been achieved, imperfection in
alignment and occlusion often developed in the long
term (Walter, 1953; Simons and Joondeph, 1973;
Little eta/., 1981, 1988; Udhe eta/., 1983; Shields et
a/., 1985). The constraints imposed by underlying
skeletal discrepancies which could not be changed
by orthodontic treatment alone were highlighted in a
review of 50 consecutively treated patients with an
original overjet of 10-15 mm. As few as 6 per cent
displayed an overjet within the normal range (Jess
than 4 mm) on follow up (Nashed and Reynolds,
1989). However, 60 per cent of all the patients had
their overjets reduced to less than 5 mm as a result
of treatment.
The aim of the study was to assess the success of
orthodontic treatment, relative to aesthetic and
dental health need.
Materials and Methods
In 1987/88, a systematic 5 per cent sample of 1225
orthodontic cases was collected by the Dental Practice
Board. The sample did not include discontinued
patients, as the information relating to these patients
was poor and, in many cases, the final study models
were not collected. During this period practitioners
were required to submit dental casts to the Dental
Practice Board for approval where treatment in-
volved more than one removable appliance, or fixed
RJOMay/994 Use of IOTN in Assessing Treatment Need 177

TABLE I Variables recorded for non-prior (200 cases) and prior approval cases (1025): number
and percentage of cases

Non-prior (%) Prior ( 0/.,)

Specialist orthodontic qualification

Yes 30 (15%) 308 (30%)
No 170 (85%) 717 (70%)
Experience-number of years since qualification
0-1 years 16 (8) 30 (3)
2-5 years 32 (16) 103 (Ill)
6-10 years 84 (42) 441 (43)
>21 years 68 (34) 451 (44)
Practitioner category
Practitioners on the BAO register 40 (20) 390 (3!l)
Practitioners completing greater than 36 cases per year 40 (20) 307 (30)
Practitioners completing less than 35 cases per year 120 (60) 328 (32)
Appliance types (prior approval cases only)
More than one upper removable 511 (50)
Upper and lower removable 48 (5)
One-arch fixed 149 (IS)
Two-arched fixed 196 (19)
Combination of appliances including myofunctionals 106 (HI)
Non-specific 15 (I)

appliances. No approval was necessary if one re-
movable 'spring type' of appliance was used. The
sample included 1025 prior approval and 200 non-
prior approval cases.
The Dental Practice Board was in a unique position,
as it processed all treatments undertaken within the
General Dental Service, providing the opportunity
for a searching enquiry free of selection bias.
Anonymous information was collected relating to
the qualifications and experience of dentists under-
taking treatment and the appliance type employed
(Table 1). This information was obtained from the
records held by the Dental Practice Board.
Recording orthodontic treatment need
Need for treatment was assessed using the Index of
Orthodontic Treatment Need (IOTN) described by
Brook and Shaw, (1989) and modified by Rich-
mond, (1990). The index has two parts, the Aesthetic
(AC) and the Dental Health (DHC) components.
The Aesthetic Component consists of a scale of
ten photographs showing different levels of dental
attractiveness (Fig. 1). The dental attractiveness of
prospective patients on pre- and post-treatment
dental casts can be identified and ranked according
to this scale. The 10 photographs have been cat-
egorized to reflect current British Dental opinion
(Richmond, 1990). Grades 1-4 represent 'No/slight
need for treatment', grades 5-7 a 'borderline need'
and grades 8-10 a 'definite need' for treatment on
aesthetic grounds. Arguably, treatment should be
undertaken for those patients presenting with a
'definite need for treatment' and as a result of ortho-
dontic care should finish in the 'no/slight need' for
treatment category.
The Dental Health Component records the vari-
ous deviant occlusal traits of a malocclusion which
would reduce the longevity of the dentition and sur-
rounding structures (Table 2). Again three grades
have been derived reflecting current dental opinion
(Richmond, 1990). Grades 1 and 2 indicate 'no
need', Grade 3, 'borderline need', and grades 4 and
5, 'definite need' for treatment on dental health
grounds. For example, overjets greater than 6 mm
would require treatment, overjets 3·5-6 mm with
incompetent lips, 'borderline need' and overjets
3·5-6 mm with competent lips 'no need' for treat-
ment on dental health grounds. The worst occlusal
feature is recorded only. The IOTN was recorded
by two calibrated examiners who showed good re-
liability before, during and after the study (Kappa
>0·66; substantial agreement).
Results
The pre- and post-treatment, aesthetic and dental
health component categories for non-prior and prior
approval patients are shown in Table 3.
Index of Orthodontic Treatment Need
Aesthetic component. Thirty-two per cent of
non-prior approval patients 'needed' treatment on
178 S. Richmond eta/.
Fro. 1 The aesthetic component of IOTN.
aesthetic grounds and this was reduced to 5 per cent
as a result of appliance therapy. Another 19 per cent
finished as a 'borderline' need for treatment on Aes-
thetic grounds. Treatment was carried out more suc-
cessfully for prior approval patients, in that only 2
per cent of treatments were still in 'need' of treat-
ment and 13 per cent 'borderline need' on aesthetic
grounds on completion of therapy.
Dental health component. For the non-prior and
prior approval patients a similar success was
achieved. Although approximately 80 per cent
'needed' treatment on dental health grounds, over
one-third still required treatment after appliance
therapy and another quarter presented with a 'border-
line need'.
The fate of individual occlusal traits. The most
deviant occlusal trait was recorded on the pre- and
post-dental casts enabling the identification of those
occlusal traits which are most likely to be fully cor-
rected (Tables 4 and 5). For example, of the 101
non-prior approval patients presenting with a cross-
bite (4.c), 35 patients still had a crossbite, and 40
patients fell into grades 1 and 2 after appliance
therapy.
In the non-prior approval cases, the most success-
BJO Vol. 21 No.2
fully treated occlusal traits were, displacement of
contact points between 2-4 mm (75 per cent success-
fully treated), 40 per cent of patients presenting with
a cross-bite were successfully treated, although in
one-third of these a cross-bite still remained or was
created after appliance therapy.
Approximately one-third of patients with overjets
over 6 mm were successfully treated. However, in
one in five patients presenting with overjets of 3·5-6
mm, the overjet increased to 6-9 mm after appliance
therapy.
Similar findings were shown for the prior approval
cases. Sixty-four per cent of patients with contact
displacements were successfully treated, as were 50
per cent of patients with overjets of 3·5-6 mm.
Approximately one-third of the patients with over-
jets greater than 6 mm, and patients with impacted
teeth were successfully treated. Of those patients
presenting with a cross-bite, over half still had a
cross-bite on completion of appliance therapy.
Approximately one-half of the patients falling in the
'no need for treatment' category became worse.
Factors influencing the outcome of treatment
The effect of the type of appliance used was assessed
in relation to start, finish, and change in IOTN.
BJOMay /994 Use of IOTN in Assessing Treatment Need 179

TABLE 2 Dental health component gradings

Grade 5 (Need treatment)

5.i Impeded eruption of teeth (except for third molars) due to crowding, displacement, the presence of supernumerary teeth,
retained deciduous teeth and any pathological cause.
5.h Extensive hypodontia with restorative implications (more than I tooth missing in any quadrant) requiring pre-restorative
orthodontics.
5.a Increased overjet greater than 9 mm.
5.m Reverse overjet greater than 3·5 mm with reported masticatory and speech difficulties.
5. p Defects of cleft lip and palate and other craniofacial anomalies.
5.s Submerged deciduous teeth.

Grade 4 (Need treatment)

4.h Less extensive hypodontia requiring pre-restorative orthodontics or orthodontic space closure to obviate the need for
a prosthesis.
4.a Increased overjet greater than 6 mm, but less than or equal to 9 mm.
4.b Reverse overjet greater than 3·5 mm with no masticatory or speech difficulties.
4.m Reverse overjet greater than I mm, but less than 3·5 mm with recorded masticatory and speech difficulties.
4.c Anterior or posterior crossbites with greater than 2 mm discrepancy between retruded contact position and intercuspal
position.
4.1 Posterior lingual crossbite with no functional occlusal contact in one or both buccal segments.
4.d Severe contact point displacements greater than 4 mm.
4.e Extreme lateral or anterior open bites greater than 4 mm.
4.f Increased and complete overbite with gingival or palatal trauma.
4.t Partially erupted teeth, tipped and impacted against adjacent teeth.
4.x Presence of supernumerary teeth.

Grade 3 (Borderline need)

3.a Increased overjet greater than 3.5 mm, but less than or equal to 6 mm with incompetent lips.
3.b Reverse overjet greater than I mm, but less than or equal to 3.5 mm.
3.c Anterior or posterior crossbites with greater than I mm, but less than or equal to 2 mm discrepancy between retruded
contact position and intercuspal position.
3.d Contact point displacements greater than 2 mm, but less than or equal to 4 mm.
3.e Lateral or anterior open bite greater than 2 mm, but less than or equal to 4 mm.
3.f Deep overbite complete on gingival or palatal tissues, but no trauma.

Grade 2 (Little)
2.a Increased overjet greater than 3.5 mm, but less than or equal to 6 mm with competent lips.
2.b Reverse overjet greater than 0 mm, but less than or equal to I mm.
2.c Anterior or posterior crossbite with less than or equal to 1 mm discrepancy between retruded contact position and
intercuspal position.
2.d Contact point displacements greater than 1 mm, but less than or equal to 2 mm.
2.e Anterior or posterior openbite greater than I mm, but less than or equal to 2 mm.
2.f Increased overbite greater than or equal 3.5 mm without gingival contact.
2.g Prenormal or postnormal occlusions with no other anomalies (includes up to half a unit discrepancy).

Grade I (None) .
1. Extremely minor malocclusions including contact point displacements less than 1 mm.

TABLE 3 Aesthetic and dental health component scores pre- and There was evidence of imbalance between
post-treatment number of cases(%) appliance groups for the pre-treatment grades of
Aesthetic Component (Table 6). The multiple com-
Dental health
Aesthetic component component
parison test (Tukey P<O·OS) revealed that the single
removable and dual arch fixed appliances had statis-
Pre- Post Pre- Post tically higher pre-treatment aesthetic component
scores than single fixed and non-prior approval
Non-prior approval-200 cases
No need 60 (30) 152 (76) 4 (2) 76 (38) cases.
Borderline need 76 (38) 38 (19) 34 (17) 54 (17) Using the Tukey multiple comparison procedures
Need treatment 64 (32) 10 (5) 162 (81) 70 (35) (P<O·OS) it was found that dual arch fixed appliance
treatment gave a significantly greater improvement
Prior approval-1025 cases in aesthetic component than all other appliance
No need 123 (12) 871 (85) 30 (3) 420 (41)
Borderline need 420 (41) 133 (13) 195 (19) 267 (26) types, and that the non-prior approval cases showed
Need treatment 482 (47) 21 (2) 800 (78) 338 (33) statistically less improvement than prior approval
cases.
180 S. Richmond eta/. HJO Vol. 21 No.2

TABLE 4 Outcome in respect of the dental health component for the non-prior approval cases (n = 200)

Post-treatment

DHC Grade I Grade 2 Grade 3 Grade 4 Grade 5 Total

pretreatment
b d e g a d a c d h a

Grade 2 d 3 3
g 2 2
Grade 3 a I 4 6 3 16
d 3 8 2 16
f I 2
Grade 4 a 5 6 I 14
c 3 8 29 13 8 35 3 101
d 2 2 7 3 5 19
h I

Grade 5 a I 4 3 I 5
3 2 6 4 20
Total 4 10 7 56 36 16 9 51 4 5 200

Abbreviations; a-overjet; b-reverse overjet; c-cross-bite; d-displacement; e-open bite; f-overbite; g-pre- and post-
normal occlusions; h-hypodontia; i-impeded eruption; s-submerged deciduous teeth; !-erupted impacted teeth; p-cleft lip/
palate.
For example, of the 101 patients who presented with a cross-bite, 35 patients still had a cross-bite and only 40 (3 + 8 + 29) patients
fell into grades I and 2 after appliance therapy.

TABLE 5 Outcome in respect of the dental health component for the prior approval cases (n = /025)

Post-treatment

DHC Grade I Grade 2 Grade 3 Grade 4 Grade 5 Total

pretreatment
b d e g a d a c d h a

Grade 2 d 4 2 2 3 13
g 5 3 4 12
Grade 3 a 7 6 60 30 3 2 19 132
d I I
f 2 4 36 12 6 4 67
Grade 4 a 7 70 70 10 2 5 48 2 1 218
c 3 II 82 37 9 126 I 2 273
d 5 4 43 22 4 3 19 I 101
h 2 2 7 12
3 2 I 6
Grade 5 a 3 25 29 2 7 21 93
i 4 2 30 20 4 5 28 96
s I
Total 25 2 38 4 35 229 38 5 n ~1 5 2 1 4 3 1025

Abbreviations; a-overjet; b-reverse overjet; c-cross-bite; d-displacement; e-open bite; £-overbite; g-pre- and post-
normal occlusions; h-hypodontia; i-impeded eruption; s-submerged deciduous teeth; t-erupted impacted teeth; p-cleft lip/
palate.
For example, of the 273 patients who presented with a cross-bite 126 patients still have a cross-bite and only 97 (3 + I + II + 82)
patients fell into grades 1 and 2 after appliance therapy.

The aesthetic component was reduced on average
by 2·1 for non-prior approval cases, compared with
3·5 for more than one removable appliance, 3·4 for
upper and lower removables, and 4·7 for upper and
lower fixed appliances.
Regarding improvement in the dental health com-
ponent (Table 7), dual arch fixed appliance treat-
ment results were superior to those produced by
single arch treatments. The mean reduction in
Dental Health Component for non-prior approval
BJO May 1994 Use of IOTN in Assessing Treatment Need 181

TABLE 6 Aesthetic component gradings, pre-treatment, post-treatment, and change

Non-prior approval Prior approval

Upper Upper + lower One arch Upper+ lower Combination
removable fixed fixed removable
AC start
Mean 6·1 7·2 7·1 6·4 6·9 6·9
S.D. 2·0 1·7 1·9 1·9 2·0 1·7
Maximum 10·0 10·0 10·0 10·0 10·0 10·0
75th Pet 8·0 8·0 8·0 8·0 8·0 8·0
Median 6·0 8·0 7·5 7·0 7·0 7·0
25 Pet 4·0 6·0 6·0 5·0 6·0 6·0
Minimum 1·0 2·0 1·0 2·0 2·0 3·0

AC finish
Mean 4·0 3·6 2-4 3·2 3·5 3·2
S.D. 1·7 1·5 1·2 1·8 1·3 1·4
Maximum 9·0 10·0 9·0 10·0 7·0 8·0
75th Pet 5·0 4·0 3·0 4·0 4·0 4·0
Median 4·0 3·0 2·0 3·0 3·0 3·0
25 Pet 3·0 3·0 2·0 2·0 3·0 2·0
Minimum 1·0 1·0 1·0 1·0 1·0 1·0

AC change
Mean 2·0 3·5 4·66 3·2 J.4 3·7
S.D. 2·0 1·9 2·01 2·2 2·2 1·9
Maximum 7·0 9·0 9·00 8·0 7·0 8·0
75th Pet 4·0 5·0 6·00 5·0 5·0 5·0
Median 2·0 4·0 5·00 3·0 4·0 4·0
25 Pet 1·0 2·0 3·00 2·0 2·0 2·0
Minimum -5·0 -2·0 -4·00 -2·0 -2·0

TABLE 7 Dental health component gradings, pre-treatment, post-treatment, and change

Non-prior approval Prior approval

Upper Upper + lower One arch Upper + lower Combination
removable fixed fixed removable

DHC start
Mean J.9 4·0 3·9 3·8 4·0 4·0
S.D. 0·6 0·7 0·7 0·7 0·6 0·6
Maximum 5·0 5·0 5·0 5·0 5·0 5·0
75th Pet 4·0 4·0 4·0 4·0 4·0 4·0
Median 4·0 4·0 4·0 4·0 4·0 4·0
25 Pet 4·0 4·0 4·0 3·0 4·0 4·0
Minimum 2·0 2·0 2·0 1·0 3·0 2·0

DHC finish
Mean 3·0 3·0 2·5 2·9 3·0 3·0
S.D. 0·9 0·9 0·9 1·0 0·9 0·9
Maximum 5·0 5·0 4·0 4·0 4·0 5·0
75th Pet 4·0 4·0 3·0 4·0 4·0 4·0
Median 3·0 3·0 2·0 3·0 3·0 3·0
25 Pet 2·0 2·0 2·0 2·0 2·0 2·0
Minimum 1·0 1·0 1·0 1·0 1·0 1·0

DHC change
Mean 0·9 1·0 J.4 0·9 1·0 1·0
S.D. 0·9 1·0 1·0 1·1 1·0 1·0
Maximum 3·0 4·0 4·0 4·0 3·0 3·0
75th Pet 2·0 2·0 2·0 2·0 2·0 2·0
Median 1·0 1·0 2·0 1·0 1·0 1·0
25 Pet 1·0
Minimum -1·0 -2·0 -2·0 -2·0 -1·0 -1·0
182 S. Richmondetal. BJO Vol. 21 No.2

cases was 0·95. For the prior approval cases the
mean reduction in Dental Health Component was
0·97 for more than one upper removable appliance,
0·9 one arch fixed, 1·02 upper and lower removable,
and 0·95 for a combination of appliance therapies.
The greatest reduction was achieved using upper
and lower fixed appliances, being 1·37.
Many recorded factors (appliance type, qualifica-
tion, experience, region) may well have had an in-
fluence on the outcome of treatment singly or in
combination. Multivariate analysis was carried out
using generalized linear modelling with GLIM statis-
tical software to determine the factors which had the
greatest influence overall (Numeric Algariths Group
Ltd., 1987). To analyse unbalanced data the residual
sum of squares together with the simultaneous testing
procedure described by Aitkin, (Aitkin, 1974, 1978;
Aitkin et al., 1989) were used. The fitting procedure
compares each model with the full model in which
factors are fitted. The simplest model for which the
F-statistic is not significantly different from the full
model is taken to be the fitted model, as it provides
an adequate but parsimonious description ofthe data.
In the analysis of both outcome measures using
generalized interactive models, of the factors con-
sidered, the strongest relationship existed between
appliance type, and the change in aesthetic com-
ponent and change in dental health component. This
can be seen from the minimal reduction of deviance
seen in Tables 8 and 9 when the variables were
added.
Therefore, when treatment was stratified in
appliances (i.e. classified according to the appliance
used), there appeared to be no statistically signifi-
cant difference between practitioner categories,
specialized qualification or experience.
Discussion
On the whole, full upper, and lower fixed appliances
brought about a greater improvement in aesthetics
and dental health components compared to other
appliance techniques, and were Jess likely to make
the occlusion worse. When treatment was classified
according to the appliance used, there appeared to
be no statistical difference between practitioner
categories, specialist qualification, or experience.
It was also revealed that cases presenting with
displacement of contact points between 2-4 mm
were more likely to improve in respect of dental
health component than cases with other anomalies.
Prior approval cases starting with a DHC grade 2,
were more likely to become worse off. A common
problem resulting from treatment was the develop-
ment of a cross-bite, arising perhaps from inadequate
adjustment of appliances.

TABLE 8 Analysis of variance for unbalanced data-reduction in aesthetic component grade

Residual Degrees Explained F p

sum squares of freedom r2

Null 5400·4 1209 0·000 14·11 < 0·0001

Appliance type 4738·4 1204 0·123 0·15 > 0·5
+ Qualification 4738·4 1203 0·123 0·15 > 0·5
+ Experience 4738·2 1203 0·123 0·15 > 0·5
+ Practitioner 4732-4 1202 0·124 0·03 > 0·5
+Region 4737·6 1201 0·123 0·13 > 0·5
Full model 4731·2 1197 0·124

Parsimonious fitted model: appliance.

TABLE 9 Analysis of variance for unbalanced data-dental health component

Residual Degrees Explained F p

sum squares of freedom r2

Null 1292-3 1209 0·000 2·56 < 0·001

Appliance type 1262·9 1204 0·023 0·23 > 0·5
+ Qualification 1262·9 1203 0·023 0·23 > 0·5
+ Experience 1261·8 1203 0·024 0·14 > 0·5
+ Practitioner 1262·8 1202 0·023 0·22 > 0·5
+Region 1261·5 1201 0·024 0·12 > 0·5
Full model 1260·0 1197 0·025

Parsimonious fitted model: appliance.

BJOMay/994
Conclusions
1. The number of patients needing orthodontic
treatment on aesthetic grounds after appliance
treatment fell by 27 per cent for non-prior approval
cases and 45 per cent for prior approval cases.
2. The number of patients needing orthodontic
treatment on dental health grounds fell by 36 per
cent for non-prior approval cases and 45 per cent
for prior approval cases.
3. Upper and lower fixed appliances had the
greatest influence on outcome of treatment in
terms of aesthetics and dental health.
4. The use of fixed appliances was more important
than practitioner categories, the possession of a
specialist orthodontic qualification and experi-
ence of the practitioners.
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