Original Article An assessment of extraction versus nonextraction orthodontic treatment using the peer assessment rating (PAR) index J. Kevin Holman, DMD, MSD; Mark G. Hans, DDS, MSD; Suchitra Nelson, PhD; Michael P. Powers, ODS, MS. ne decon ext teh fo nthoon- Sujets nthe orf the spel 1507, Edward H. Ange posed ht ming Se yearn lthough most alos stfu siy waoften ot scheved? Al nonextraction treatment remained the standard until the 1940s, In the 1980s, many practitioners began to ob- serve generalized relapse with nonextraction treatment. Charles H. Tweed presented a paper advocating the extraction of all four first premolars Using cephalometric analysis to sup port his position, Tweed initiated a swing among the orthodontic community toward extraction therapy. ‘The popularity of extraction therapy lasted well into the 1970s, During the 1980s, the pendulum swung back toward nonextraction, and that Abstract, The extraction of teeth for orthodontic purposes has always been a controversial subject in the specialty. The purpose of this study was to assess the outcome of orthodontic treatment in 100 patients treated with the extraction of four premolars ‘and compare it with the outcome of 100 patients treated without extractions, using the peer assessment rating (PAR) index. Records were selected from 1,198 consecutively completed cases treated by a single provider (MGH) between 1981 and 1995, We chase the first 100 finished patients in each group (extraction and nonextraction) who were under the age of 16 land had no deciduous teeth at the start of treatment, The results of this study show that average treatment time for the ‘extraction group was 29.7 = 6.1 months compared with 26.0 + 7.2 months for the nonextraction group, The extraction group ‘had significantly higher initial PAR scores (T1-PAR ext = 30.01 = 6.20 vs. T1 PAR nonext = 25.21 = 8.55}, with greater inital ‘maxillary anterior crowding (PAR ext value = 6.05: 3.85 vs. PAR nonext value =4.21 # 2.90) and greater initial overjet (PAR ext value = 1.82 + 1.01 vs, PAR nonext value 1.28 + 1.04). All pretreatment dferences were significant at the p< 0.0001 level. Although significantly different at the beginning of treatment, both groups were statistically identical at the end (PAR ‘T2ext= 6.18 + 3.04% reduction = 79.4% compared with PAR T2 nonext = 5.64 + 3.08% reduction = 77.6%). In conclusion, the results demonstrate that, given an additional 3 months of treatment, itis possible for an orthodontist to produce dento- ‘occlusal relationships in extraction patients that are as good as those achieved in nonextraction cases. Key Words ‘Orthodontic treatment * Extraction + PAR score + Outcome assessment ‘Submitted: January 1998 Revised and accepted: Apri! 1998 ‘Angle Orthod 1998,68(6):527-534, ‘The Angle Orthodontist Vol. 68 No. 6 1998 SurHolman; Hans; Nelson; Powers 528 ‘The Angle Orthodontist trend persists today. The resurgence of rnonextraction therapy is probably the result of many factors, including the renewed popularity of early intervention, a greater acceptance of functional appliances in the United States, and the change from fully banded appliances to di rect-bonded brackets. Finally, a consumer-driven ‘market for treatment without extractions, com- bined until recently with a conspicuous lack of experimental evidence to support either position, thas ultimately kept the extraction-nonextraction debate at the forefront of orthodontic concerns. In a respected specialty such as orthodontics, the decision to extract or not should, at least in ppatt, be based on scientific assessments of treat- ‘ment outcome. Paquette et al? provided an ex- cellent example of the type of studies that are needed. These researchers compared the cepha- Tometric changes that occurred in a group of bor- derline extraction cases treated with or without the removal of premolars, They concluded that the profile was 2 mm flatter in the extraction group. This type of information allows the clini- cian to make an informed decision, However, the extraction-nonextraction debate continues, sug- gesting that more objective information is needed. It is hoped that the existence of more data will prevent the debate from hinging on the clinical experience of the most persuasive spokesperson. ‘The present study used the peer assessment rating (PAR) index to objectively assess the out- ‘come of extraction and nonexteaction orthadon- tic treatment in a sample of 100 extraction and 1100 nonextraction cases, This index, which uses pretreatment and posttreatment study models, thas been shown in previous studies to be a valid and reliable method of assessing the outcome of ‘orthodontic treatment By examining statistical dlfferences in PAR scores between extraction and rnonextraction cases, this study will provide part ‘of the answer to the basic clinical questions: Are the teeth straighter? Is maximum intercuspation better after extraction or after nonextraction therapy? Materials and methods From a population of 1,198 consecutively com- pleted orthodontic cases of a single provider (MGH) treated between July 1981 and December 1995, the principal investigator JKH) reviewed the study models and other patient records to es- tablish a study sample of 200 cases—100 treated with the extraction of four first premolars and 100 treated without the extraction of permanent teeth, Vol. 68 No, 6 1998 ‘Only adult dentition cases were selected be- ‘cause several authors” have questioned the use of the PAR index in scoring mixed dentition cases, After the initial screening of pre-and post- treatment dental casts, treatment records were reviewed to determine the age of the patient at the start of treatment. Only patients below the ‘age of 16 were chosen. This was done to elimi- nate nongrowing or slow-growing subjects from the study sample. Likewise, patients with con- genital craniofacial defects, such as cleft lip and palate, were not included. The following data ‘were abstracted from the treatment records of the selected patients: birth date, treatment start date, race, sex, date braces were removed, and occu- pation of the parent or guardian responsible for the orthodontic care, From this data, the age at the start of treatment and the duration of treatment (months) were computed, The first 100 extraction and 100 nonextraction cases that met the inclusion crite- ria were chosen for the study. All treatment was completed by one provider (MGH) using .018 pretorqued, preangulated brackets (“A"-Com- pany, San Diego, Calif). The pre- and posttreat- ment study models were first classified as extraction or nonextraction and then categorized by Angle classification. Although not excluded from the sample by design criteria, no corthognathic surgery patients were enrolled. The PAR index was used to assign a number to each set of dental casts. A complete description of the PAR index is presented in Am Introduction t0 Oc- ‘lusal Indices* Briefly, each set of dental models is occluded in maximum intercuspation and a calibrated PAR ruler is used to assign a value to ‘each of the five weighted components. The five weighted components are: upper anterior seg- ment alignment (UAS); right and left buccal oc- ‘clusion (RBO, LBO); overjet (Q)); overbite (OB); and midline deviation (MID), The weighting in the American system is as follows: UAS times 1, RBO and LBO times 2, OJ and OB times 3, and MID times 2. A perfect occlusion would receive a score of zero; a score from one to nine indicates that good dental relationships are present; a score above 40 indicates severe malocclusion. All study models were scored by one investigator (IKH), who was trained in the use of the PAR index by Dr. Kevin O'Brien, senior lecturer in orthodontics, Manchester, England. The paren- tal occupation coding (socioeconomic assess- ‘ment) was determined from the patient's initial health history questionnaire and was categorized using a modified Hollingshead analysis.” The total sample of 100 extraction and 100rnonextraction cases (N = 200) was scored accord- ing to the PAR eriteria and weighted for maloc- clusion severity and treatment difficulty using the weightings derived from the US (Pittsburgh) validation session.” All individuals in the sample were Caucasian. ‘The data were analyzed, using the Statistical Package for the Social Sciences for Windows soft- ‘ware (SPSS, Inc, Chicago, Il). Means and stan- dard deviations for the patient's age at the start of treatment, total active treatment duration, pre- treatment and posttreatment PAR scores, and individual PAR components were obtained. The parental occupation coding was divided into rine general groups. Means, standard deviations, and frequencies were calculated for the socioeco- nomic assessment, Frequencies for the extraction group, the nonextraction group, and the total sample were then calculated for Angle classifi- cation and sex. ‘Treatment outcome can be assessed using the PAR index in two ways: using the numerical re- duction in the weighted PAR score or using the percentage reduction in the weighted PAR score. Since the American weighting system was used in this study, the most appropriate outcome as- sessment measure for the PAR index was the percentage reduction in weighted PAR score for both the extraction and the nonextraction groups This is determined by the formul Xd = X2/X1 x 100%, where X1 = pretreatment PAR score and X2= posttreatment PAR score ‘The percentage reduction (% RED) of each PAR component was also computed, using this same formula, Finally, a calculation was done for the percentage that each individual PAR component contributed to the total malocclusion (% MAL). ‘This was determined by multiplying the pre- treatment PAR score of each component by its specified weighting, then dividing by the total pretreatment PAR score for each treatment ‘group. Next, a linear regression model was for- mulated to determine the effect each indepen- dent variable had on the dependent variable. The difference in pretreatment and posttreatment PAR scores was considered the dependent vari- able. The following independent variables were entered into the multiple regression model: 1. group (extraction or nonextraction) Angle classification patient age (years/months) active treatment duration (months) 6. estimate of socioeconomic status A stepwise model was calculated to determine which individual factors contributed signifi- 2 3 4 5, Extraction, nonextraction treatment assessed using the PAR index cantly to the outcome variable. A second linear regression model was formulated to determine which factors were significant in causing a per~ centage reduction in PAR score. The indepen- dent variable pretreatment PAR score was added, along with the other independent vari- ables, to the equation. Stepwise variable selec- tion was used to determine which independent variables contributed most to the changes ob- served in the dependent variable, T-tests were run on all independent variables to test for sta tistical differences in these factors between the extraction and nonextraction groups. Alpha val-~ ues were set at p $0.08. Intraexaminer reliability During the initial data collection (T,), all pre- and posttreatment study models were scored according to the PAR index criteria. Approxi- mately 4 weeks later, 33 cases were randomly selected from the entire sample and the PAR score was determined a second time (Ty). In or- der to test for bias, a test of reliability was caleu- lated using an intraexaminer correlation cootficient of reliability. Comparisons were made between pretreatment T, vs. pretreatment Ty, posttreatment T, vs. posttreatment Ty, and pre- treatment T, ~posttreatment T, vs. pretreatment ‘Ty~ posttreatment Ty Results Extraction group In the extraction group (N = 100), 39 subjects ‘were male and 61 were female. The breakdown bby Angle classification is given in Table 1. All subjects were Caucasian, and the average age was 13.5.£1.4 years. The average treatment time ‘was 29.7 + 6.1 months. The mean and standard deviation (SD) for each pretreatment and post- teeatment component that makes up the PAR score, the percentage reduction in PAR score (% RED), and the percentage that each component contributed to the malocclusion (% MAL), are given in Table 2 Nonextraction group In the nonextraction group (N = 100), 50 pa- tients weee male and 50 were female. All were Caucasian, and the average age was 13.5 + 1.2 years. The average active treatment time was 260 = 72 months. Angle's classification criteria is given in Table 1. Means and standard deviations (SD) for the pretreatment and posttreatment components that make up the PAR score, as well as percentage reduction in PAR score (% RED) and the percentage that each component contrib- uted to the malocclusion (% MAL), are given in Table 3 ‘The Angle Orthodontist Vol. 68 No. 6 1998 529Holman; Hans; Nelson; Powers Table 1 Classification of subjects in each group Angle Extraction Nonextraction Tolal classification ip ‘group Class! 40 34 98 Class Il Division + 35 29 64 Class II Division 2 4 3 7 Class II Subsivision Fight or lft 14 " 25 Class I 7 3 10 Total 100 100 100 Table 2 Extraction group. Mean and stan PAR score vas BO Lo oy oa mio rd deviation (SD) for PAR score id PAR components; %RED and %MAL SERED Proireaiment Mean SD. 30.01 8.20 605 3.85 201 1.18 212 1.22 1.82 1.01 1.92 0.91 088 0.8t Postireaiment Mean SD. 618 0.09 0.82 tt ota 0.40 on MAL 3.04 02 ot 949 028 oss oat 79.41 98.51 59.20 47.64 92.31 69.70 87.50 20.16 13.40 14.13 30.32 13.20 20 30 Total sample In the total sample (N = 200), 89 subjects were male (44.5%) and 111 (65.5%) were female. All subjects were Caucasian, and the average age ‘was 13.5+ 1.3 years. The average treatment time was 27.9 + 69 months, Angle classification is given in Table 1, and means and standard de- Viations (SD) for the pretreatment and posttreat- ment components that make up the PAR score, ‘as well as percentage reduction in PAR score (% RED) and the percentage that each component contributed to the malocclusion (°% MAL) are given in Table 4 ‘Mean, standard deviation, and frequencies for occupation of each parent responsible for the orthodontic care were also calculated. The paren- tal occupations were divided into nine general categories, and the results are given in Table 5. ‘The average occupation coding for the total sample was 3.71 + 2.03. Socioeconomic status did not impact any of the outcome variables measured, The Angle Orthodontist Vol. 68 No.6 1998 inear regression The first linear regression model used the dif- ference between pretreatment and posttreatment PAR scores as the dependent variable, and R’ 0.14569 with a significance of p = 0.0001. Stepwise regression revealed that the only factors relevant to the difference in PAR score were group (ex traction or nonextraction) and initial Angle clas- sification. Group contributed an R? = 0.065580 to the difference in PAR score, Angle classification contributed R= 0.10991 ‘The second linear regression model used the percentage reduction in pretreatment and post- treatment PAR scores as the dependent variable, The results showed R? = 0.20899, with a signifi- cance of p= 0,0001, Stepwise regression revealed two significant factors, pretreatment PAR score (RE = 0.11579) and experience of the operator (R* = 0.19104). Differences between the extraction and nonextraction groups were also evaluated using ‘univariate paired t-tests. Four variables (pretreat- ment PAR, upper anterior segment crowding, pretreatment overjet, and treatment duration) ‘were statistically different between the extraction and nonextraction groups. (See Table 4.) Reliability Intraexaminer correlation coefficient results re- vealed little evidence of bias. Pretreatment T, versus pretreatment Ty was F = 0.96, Posttreat- ment T, vs. posttreatment Ty was 12 = 0.90. Pre treatment T, - posttreatment T, vs. pretreatment ‘Ty posttreatment Ty was calculated at F = 0.94 ‘The results indicated excellent intraoperator re- liability for the investigator scoring the casts. Discussion The intent of this study was to identify differ: ences in dental parameters between patients treated with premolar extractions and those treated without, Changes in dental parameters ‘can be measured in two ways using the PAR in- dex: numerical reduction in the weighted PAR score and percentage reduction in the weighted PAR score. Because this study used the US. ‘weighting system, the most appropriate measure of improvement is the percentage reduction in weighted PAR score, Previous studies have shown that a 65% reduction in PAR score can be considered a great improvement in occlusal fac tors. In this study, the extraction group showed a 79.41% average reduction in PAR score, with 89 patients having a percentage reduction of at least 65%, Likewise, the nonextraction group had 2 percentage reduction of 77.63%, with 85 pa- tients having percentage changes of atleast 65%,Extraction, nonextraction treatment assessed using the PAR index ‘Therefore, good to excellent dental results were achieved for both groups. This finding indicates that practitioners should base extraction deci- sions on factors other than quality of the dental relationships that can be achieved at the end of treatment. Although the overall means in percentage re- duction in PAR score were identical, the pretreat ‘ment means were not, Paired t-tests showed that for four of the five weighted components (UAS, RBO/LBO, OJ, MID), the mean pretreatment PAR scores were greater in the extraction group. ‘This indicates that a more severe dental maloc- clusion was present for these patients, Premolar extraction was associated with more crowding, a more severe buccal segment occlu sion, greater overjet, and a larger midline devia tion, These findings are consistent with those of Paquette etal.’ who reported that the discrimi nant function used to identify their group of bor- derline extraction cases included measures of dental crowding and overjet. This interaction between the initial severity of the malocclusion and the extraction decision indicates that the samples studied exhibited susceptibility bias, ie, some individuals were more likely to be treated with extraction than others, However, this sus: ceptibility bias would be important only if there Was a difference in the groups at the end of treat ment. Ifa difference was found at the end of tweatment, it would be difficult to tel if it was due toa difference that existed at the beginning. In this study, the groups were different at the beginning of treatment and identical at the end. Therefore, greater susceptibility to one or the other treatment strategies is an interesting but ‘inconsequential bi Extraction treatment seems to be more preva~ lent in cases having more severe malocclusions. For example, previous studies conducted on samples treated in the US. have reported that 2 pretreatment PAR score greater than 40 repre: sentsa severe malocclusion. Inthe present study, 10 cases (10°%) in the extraction group hael an ini tial PAR score greater than 40, In contrast, only four cases (4%) in the nonextraction group had initial PAR scores greater than 40. Therefore, traction treatment is probably more likely among, cases with severe malocclusion. Pretreatment PAR score (ie, the severity of the initial dental malocclusion) also entered the stepwise linear regression model that used percentage reduction in PAR as the dependent variable, Both these fac- tors suggest that the more severe the initial mal- ‘occlusion, the greater the possibility that the case will be treated with the extraction of premolars, Table 3 Nonxtraction group. Mean and standard deviation (SD) for PAR ‘score and PAR components; % RED and % MAL Pretreatment Posttreatment % RED % MAL Mean SD Mean SD. PAR score 2521 855 564 3087763 vas 421 290 0.15 048 © 96.44 16.70 REO 183 116 072-059 «60.66 1452 Lo 202 190 094 087 5347 1603 oy 128 104 = 0.11 0319.41 25.39 oB 158 088 © 042-052 «©7342-1880 Mio 072 079 012 033 93.33 857 Table 4 ‘Total sample. Mean and standard deviation (SO) for PAR score and PAR components; % RED and % MAL Pretreaiment Posttreatment 9% RED %e MAL Mean SD__Mean SD. PAR score 2761 870 5.91 306 78.59 uas 513 952 012 041 97.66 18.58, BO 192 117 077 051 59.90 13.91 Lo 207 126 © 103053 50.24 14.99 oo 155 101 0.13035 91.61 28.07 oB 145 0.90 O41 052 71.72 18.76 MD ogo 080 0.12 032 «85,008.69 Itis interesting to note that pretreatment over- bite did not differ significantly between the two groups. In fact, pretreatment overbite is the only ‘component that was greater in the nonextraction group. It is possible that dental overbite (OB) is 4 surrogate measure for decreased lower facial height or diminished vertical dimension. The extraction group had a smaller averaged OB component PAR score than the nonextraction group (1.32 vs. 1.58), implying that more high- angle or openbite patients may have been in the extraction sample, On the other hand, low-angle, deepbite patients were probably more common in the nonextraction sample. In some cases, ex- tractions are necessary to close openbites, whereas many deepbite cases are completed without extracting teeth. Therefore, the scores for the different components of the PAR index con- firm statistically what is “felt” clinically. Several interesting findings relate to the per centage reduction (% RED) calculated for each The Angle Orthodontist Vol. 68 No. 6 1998 531Holman; Hans; Nelson; Powers ‘Major professionals Lesser professionals Skilled manual workers Unskiled workers Selt-employed ‘Small business owners and managers, Clerical and sales workers Semi-skiled manual workers No occupation givenlunemployedireticod 5 Table 6 Significant differences between extraction and nonextraction groups Extraction Nonextraction Significance ed Mean SD _Mean+SD 40 29 Pretreatment PAR score 90.0482 25.2+86 0.0001, 82 Pretreatment upper anterior 18 segment crowding (VAS) 6.1239 42429 0.0001 3 Pretreatment overjet (OJ) 18£1.0 1321.0 0.0001 2 Treatment duration 297261 260272 0.0001 532 The Angle Orthodontist individual component of the PAR index. For ex- ample, in both the extraction and nonextraction groups, scores for upper tooth irregularity (VAS), overjet (O)), and midline deviation (MID) ‘were reduced more than 85%, In contrast, over- bite (OB) was reduced less than 75%, and RBO and LBO were reduced only about 55%. These findings suggest that the clinician found it much more difficult to effect changes in molar relation- ship and overbite than to correct anterior crowd- ing or overjet. Interestingly, these factors did not ‘seem to be related to whether or not teeth were ‘extracted in the process. Most orthodontists and patients are concerned with the length of active treatment. By having estimates of treatment duration, clinicians can offer more accurate information during consul- tations with potential patients. In this study, treatment duration was measured from the time the appliances were first placed (band/bond date) until the day the appliances were removed {deband date). For the extraction group, the av- erage active treatment time was 29.7 months, and the nonextraction group had an average treat- ment time of 26.0 months, a difference of 3.7 ‘months. This finding has been confirmed in other studies."*° This study demonstrates that if the clinician waits to begin treatment until all per- ‘manent teeth erupt, then extracting teeth will in- crease treatment time by about 3 months. ‘Two linear regression models were examined, ‘The first used the difference in pretreatment and posttreatment PAR score as the dependent vari- able. Surprisingly, only 15% of the variability in the samples was explained by this model. Stepwise regression identified extraction/ nonextraction group and initial Angle classifica- tion as the most significant factors. A second lin- Vol. 68 No. 6 1998 car regression model used percentage PAR score reduction as the dependent variable. This model explained 21% of the variance and identified op- ‘erator experience and pretreatment PAR score as significant factors. These findings suggest that almost 80% of the variability in percentage PAR reduction and 85% of the difference in PAR score was influenced by factors not included in the model, In other words, the majority of the vari- ability in orthodontic treatment outcome, as as- sessed by these dependent variables, seems to be due to factors not included in the model. For ex- ample, the alignment of teeth and the resulting ‘occlusion at the end of treatment could be related to the finishing goals of the person who is de- ciding when to remove the braces. This study ‘examined only one operator, so the influence of different operators on outcome could not be used in the linear models, ‘There was a positive, direct correlation between the experience of the operator (MGH) and the percentage reduction in PAR score. Although this finding supports the common belief that op- erators improve with time, the results here should be viewed with caution due to the selec- tion process of the cases. As stated in the Mate- rials and methods section, cases were reviewed beginning with case number one. In order to ob- tain 100 extraction cases that met the defined cr teria, it was necessary to review many more ‘extraction cases than nonextraction. This meant that some of the extraction cases selected were treated after the provider had been in practice for 5 years; the practitioner would naturally have more experience by then, and the extraction group would relate to the experience of the op- erator in a dependent fashion. In a study of hos- pital-based orthodontic clinics in England andWales, O’Brien etal. confirmed that operator ex- perience did relate to percentage reduction in PAR score." They found that senior operators improved cases 70.8%, while junior operators improved cases only 63.8%. Further studies on this question are needed, ‘The second variable that entered the stepwise ‘model was the initial pretreatment PAR score, This is probably due to the fact that, while there is no upper limit for pretreatment PAR score, there is a lower limit of zero, For example, re- ducing a pretreatment PAR score from 50 to 10 results in a percentage reduction of 80%. If the pretreatment score had been 52 and the posttreat ment score 10, then the percentage reduction would increase to 80.8%. Therefore, higher pre treatment PAR scores allow for greater percent age reductions. Limitations of the PAR index ‘While there are many benefits in the use of the PAR index, numerous limitations must also be remembered. The PAR index measures only dento-oeclusat change, It does not take inte ac- count changes in the soft tissue that result from orthodontic treatment, and it does not measure ‘orthodontic treatment need. Because the PAR in- dex measures only the change in malocclusion from beginning to end of treatment, it should not be used for screening, potential orthodontic pa- tients for allocating third-party payment plans; and because the index measures only study mod- els, it does not account for decalcification, gin- gival recession, root resorption, or TMJ considerations that may zesult from orthodontic treatment. This study used immediate posttreatment records, so the long-term stability of the results could not be examined. Also, only dental casts were measured; other diagnostic aids, such as. cephalograms and patient photographs, were not used, The PAR index is not sensitive to the highly specific or fine details of an ideally fin- ished case. Several authors have questioned the use of the PAR index in the scoring of mixed den- tition cases. tis also not advised for gracing lim- ited treatment cases, since only limited goals would be sought by treatment, ‘Summary and conclusions ‘The results of this study show that, on average, extraction orthodontic treatment takes 3.7 months longer to complete than nonextraction therapy. In addition, PAR index scores of extrac tion patients were significantly higher pretreat- ment as a result of higher scores for upper anterior segment crowding (UAS) and overjet Extraction, nonextraction treatment assessed using the PAR index (Ol) The percentage reduction in weighted PAR score was 79.41% for the extraction group and 77.63% for the nonextraction group. This indi- cates an excellent improvement in dento-occlusal relationships as well as orthodontic treatment to hhigh standards in both groups. In all five com- ponents of the PAR index, the extraction and onextraction groups were indistinguishable at the end of treatment. ‘The results also show that, although marked differences in extraction and nonextraction groups existed pretreatment, the groups were Statistically identical at the end of treatment. This suggests that whether or not teeth are extracted, the clinician is able to complete the cases equally well. With the increased interest in outcome assess- ‘ment in orthodontics, a method for measuring isneededl Since the specialty is not in agreement concerning this matter, one way to quantify out- ‘comes is by using occlusal indices. The PAR in- dex was developed specifically to measure ‘outcome. It has proven valid and reliable in this assessment, and it reduces subjectivity by the index’s defined criteria, The PAR index isa rapid and accurate method of measuring dento-oc- ‘lusal changes from study models, The index is ‘easy to learn and can be taught to nondental per- sonnel. It ensures uniform interpretation of re- sults and is sensitive enough to be used for research and epidemiological data collection. It hhas been recommended for use in personal au- dlits for quality assurance and for comparison of various systems of patient care delivery. Author Address ‘Mark G, Hans Dept. of Orthodontics Case Western Reserve University 10900 Euclid Avenue Cleveland, OH 44106-8905 mgh#@po.cwru.edu eoin Holman isin private practice in Tupelo, Miss. Mark G, Hans, associate professor and chairman, Department of Orthodontics, Case Western Reserve University, Cleveland, Ohio. Suchitra Nelson, PhD, assistant professor, Depart- ment of Community Dentistry, Case Western Reseroe University, Cleveland, Ohio, ‘Michael P. Powers, DDS, MS, associate professor and chairman, Department of Oral and Maxillofacial Surgery, Case Western Reserve University, Cleve lend, Ohio Research supported by the CWRU Orthodontic Alusnni Endowment Fund ‘The Angle Orthodontist Vol. 68 No. 6 1998 533Holman; Hans; Nelson; Powers 534 The Angle Orthodontist References Richmond 5, Shaw WC, OBrien KD, Buchanat IB, Jones R, Stephens CD, etal The development of the PAR index (Peer Assessment Rating): Reiabil- ity and validity. Bur J Orthod 1992; 14:125-199. Angle EH, Malocclsion ofthe teeth. $5. White Dental Manafactaring Co, 1907 Case CS. The question of extraction in orthodon- tia, Trans NDA 1911; (reprinted Am J Orthod 1964; 50:660-£91) Tweed CH. Indications for the extraction of teeth in orthodontic procedure. Am J Orthod 1944; 20405128. 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