The Irregularity Index: A quantitative

score of mandibular anterior aZignment

Robert M. little, D.D.S., M.S.D., Ph.D.*
Seattle, Wash.
A nterior dental crowding is perhaps the most frequently occurring
characteristic of malocclusion; yet the term crowding is one of the most ambig-
uous terms in the dental vocabulary. Patients, parents, the public, and the pro-
fession 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, sig-
nificant, etc. are descriptively helpful but still allow a wide range of interpreta-
tion.
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 treat-
ment 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 crowd-
ing 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 mal-
occlusion relative to a preconceived orthodontic normal or ideal. Several mal-
Assistant Professor, Department of Orthodontics, School of Dentistry, University
of Washington.
554
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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 evalua-
tion among examiners.
Several methods of assessing incisor crowding have been proposed. Barrow
and White6 described crowding in terms of fractions of permanent central in-
cisor width. For example, mandibular crowding of a given case could be de-
scribed 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 nor-
mal 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 in-
volved 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 dis-
ease 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.11-14 For example, Popovich and Thompson14 found an association
556 Little
Fig. 1. Technique involves measuring the linear distance from anatomic contact point to
adjacent anatomic contact point of mandibular anterior teeth, the sum of five measure-
ments representing the Irregularity Index.
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 in-
creased 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 con-
tact 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 ac-
cess 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
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Irregularity Index 557
Figs. 2 awl 3. Calipers should be held parallel to the occlusal plane, measuring only
horizontal linear displacement of anatomic contact points.
onto the incisal edges of the anterior teeth, the caliper held parallel to the oc-
clusal 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 ad-
jacent 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 dis-
regarded. It is then important for the evaluator to hold the caliper consistently
parallel to the occlusal plane while obtaining each measurement, thereby ensur-
ing the recording of only horizontal displacement.
558 Little
Am. J. Orthod.
November 191.5
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 sug-
gested that mesiodistal spacing be disregarded, provided the teeth in question
Volume 68
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Irregularity Index 559
are
on1
an
an1
val
Fig. 4 (Contd). For legend, see opposite page.
: in proper arch form; if spacing as well as displacement or rotations is not
4
y the labiolingual displacement from proper arch form is recorded. Althou
-&
argument could be made for the treatment of spacing as a negative value in
;erior irregularity, in this study it was determined that subtracting spa4
.ng
ues from the total would inappropriately distort the meaning of the irreg
P
560 Little
larity index-a value intended to represent crowding or deviation of teeth
relative to anterior arch form.
Materials and 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 re-
liability 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
Irregularity Index 561
INCISOR IRREGULARITY
Extreme 10
f I
r = .Sl
Perfect 0-i - I I I . I . I , 1 . , I
0 2 4 6 8 IO 12 14 16 IS
Irregularity index
Fig. 5. A scattergram demonstrating the degree of association between crowding of man-
dibular anterior teeth as assessed subjectively and by means of a quantitative technique
(r = 0.81).
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 re-
jected 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 re-
maining eighteen casts, which accounts for the presence of interaction. Exam-
ination 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 ap-
proximately 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,o-
graphs, and other diagnostic data. Perhaps the orthodontist rates severity of
crowding by comparison with other similar cases, ease of correction, the skeletal-
facial-dental pattern, the long-term prognosis, or other standards based on ex-
perience 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 be-
tween trials for six of the seven examiners showed no significant difference be-
tween first and second measurements on the same casts (p < 0.01) and no in-
dication 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 sig-
nificant 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 sub-
jective and hand-measured scores demonstrated by a correlation coefficient of
r = 0.81. Apparently, there is a predictable linear trend between clinical as-
sessment and the proposed Irregularity Index.
The Index is not an arch length assessment but, rather, a guide to quanti-
fying 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. An-
terior spacing without rotation and/or labiolingual displacement would re-
ceive no score and must be differentiated from a case demonstrating spacing plus
irregularity and deviation. In summary, the Irregularity Index is simple, clini-
cally reliable, and valid but is not without error. The major problem is a tend-
ency to exaggerate cases with considerable irregularity but little arch length
shortage. The Index does not take into account the patients cephalometric pat-
tern, facial esthetics, age, tooth morphology, the effect of habit correction, etc.-
Volume 68
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Irregularity Index 563
factors which must be considered in addition when one is assessing a case and
formulating a comprehensive diagnosis.
Summary
A quantitative method of assessing mandibular anterior irregularity is pro-
posed. 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 measure-
ments 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 sim-
ple 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 of malocclusion: A systematic
approach for planning treatment, AM. J. ORTHOD. 64: 258-269, 1973.
6. Barrow, G., and White, J.: Developmental changes of the maxillary and mandibular dental
arches, Angle Orthod. 22: 41-46, 1952.
7. Moorrees, C., and Reed, B.: Biometrics of crowding and spaqing of the teeth of the
mandible, Am. J. Phys. Anthropol. 12: 77-88, 1954.
8. Van Kirk, L., and Pennel, E.: Assessment of malocclusion in population groups, Am. J.
Public Health 49: 1157-1163, 1959.
9. BjSrk, A., Krebs, A., and Solow, B.: A method for epidemiological registration of
malocclusion, Acta Odontol. Stand. 22: 27-41, 1964.
10. Carlos, J.: Evaluation of indices of malocclusion, Int. Dent. J. 20: 606-617, 1970.
11. Freer, T., Grewe, J., and Little, R. : Agreement among the subjective severity assessment
of 10 orthodontists, Angle Orthod. 43: 185-190, 1973.
12. Hermanson, P., and Grewe, J.: Examiner variability of several malocclusion indices,
Angle Orthod. 40: 219-225, 1970.
13. Grewe, J., and Hagan, D.: Malocclusion indices: A comparative evaluation, AM. J. ORTHOD.
61: 286-294, 1972.
14. Popovich, F., and Thompson, G.: A longitudinal comparison of the orthodontic Treatment
Priority Index and the subjective appraisal of the orthodontist, J. Public Health Dent.
31: 2-8, 1971.
15. Peck, H., and Peck, S.: An index for assessing tooth shape deviations as applied to the
mandibular incisor@, AM. J. ORTHOD. 61: 384-401, 1972.
lSohoo1 of Dentistry, University of Washington (98195)