RESEARCH

IN BRIEF

This paper investigates a new orthodontic occlusal index, the Index of Outcome, Complexity and Need
(ICON). It suggests that this single index can replace the PAR index and the Index of Orthodontic
Treatment Need (IOTN). The implications are:
The single index (ICON) which is easier to learn and use than PAR and IOTN could measure orthodontic
treatment need and treatment standards.
The index could be easily incorporated into the orthodontic assessment of a patient in general dental practice.
The inclusion of IOTN in the general dental services has been proposed. ICON would be quicker to learn,
apply and more information could be gleaned than just treatment need.

A comparison of the Index of Complexity

Outcome and Need (ICON) with the Peer
Assessment Rating (PAR) and the Index of
Orthodontic Treatment Need (IOTN)
N. A. Fox,1 C. Daniels2 and T. Gilgrass3
Aim To evaluate any relationship between ICON, IOTN and PAR. To
establish whether or not ICON could replace these indices as a measure
of orthodontic treatment complexity, outcome and need.
Method The study models of 55 consecutively treated cases were
examined and PAR, IOTN and ICON recorded.
Results The study showed significant correlations between IOTN and
ICON with respect to need and PAR and ICON with respect to outcome.
Conclusion It appears that ICON does reflect UK opinion and the current
study provides some evidence that ICON may effectively replace PAR and
IOTN as a means of determining need and outcome.

The PAR Index and IOTN have now become widely used in the UK
as orthodontic audit tools. They have provided valuable data to
inform political and clinical debate on the quality of GDS orthodontics. The introduction of IOTN in the General Dental Services is
currently being considered. In order to assess treatment inputs and
outcomes using IOTN and PAR, two different measurement protocols must be learned and this duplication of effort is inefficient.
The PAR index has been accused of both undue leniency on
poor finishes1 and undue harshness on treatments with limited
aims.2,3 Experience with IOTN has shown that the need for treatment does not necessarily equate to the complexity of the treatment. It is important to make an assessment of complexity for the
following clinical reasons (Richmond et al4):
To identify the most appropriate setting in which a patient
should receive treatment.
To allow meaningful assessment of treatment outcomes.
To identify cases that are likely to take longer to treat.
To inform the patient of the likely success.
1*Consultant Orthodontist, Orthodontic Department, Middlesbrough General Hospital,
2Lecturer in Orthodontics, Department of Dental Health and Development, University

Dental Hospital, NHS Trust, Heath Park, Cardiff. 3Consultant Orthodontist, Orthodontic
Department, Newcastle Dental Hospital,
*Correspondence to: Nigel Fox, Orthodontic Department, Middlesbrough General Hospital,
Ayresome Green Lane, Middlesbrough, Cleveland TS5 5AZ
Email:[email protected]
Refereed paper
Received 14.06.01; Accepted 19.04.02
British Dental Journal 2002; 192: 225230
BRITISH DENTAL JOURNAL VOLUME 193 NO. 4 AUGUST 24 2002

Richmond et al4 found that the factors which may determine

the professional perception of orthodontic treatment complexity
include:
Cost of treatment
Number of appointments
Length of appointments
Age of patient when treatment commenced
Initial PAR Score
However they discounted most of these treatment factors as little use in the formulation of a complexity index because they were
too dependent on the choices and efficiency of the clinician. The
PAR score was suggested to be an interim possibility in the development of a complexity index.
The ICON index5 has been developed recently and claims
among other things, to evaluate orthodontic treatment complexity.
ICON is based on the subjective judgements of 97 orthodontists
from nine countries on 240 initial and 98 treated models.5 The
index is described in full in the appendix. In brief, the index comprises five weighted measurements, and owes some of its structure
to IOTN and PAR. The measured traits include:
Dental aesthetics as measured by the aesthetic component of
IOTN.6
The presence of a crossbite
Anterior vertical relationship ie deep bites and open bites as
measured by PAR.7
Upper arch crowding/spacing on a five point scale
Buccal segment antero-posterior relationship as measured by
PAR.7
The sum of the weighted scores is interpreted using cut-off values and score ranges to indicate the treatment need, complexity
and degree of improvement. The cut-off values are to give the
index meaning and link the numerical ICON score to the original
subjective description of the 97 orthodontists. It is claimed that
using ICON to make these assessments is more efficient (than PAR
and IOTN) because it requires only a single measurement protocol.
ICON should prove to be a useful tool for research and audit, but if
used alongside PAR and IOTN, could be an additional burden in a
busy hospital or practice setting.
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RESEARCH
PAR and IOTN have been validated against UK dental opinion7,8 and in an increasingly global environment, perhaps a more
internationally recognised standard should now be sought. ICON
reflects the views of 97 orthodontists from eight European countries and the USA, and may provide an acceptable alternative to
IOTN and PAR.
The aim of this paper is to investigate any link between PAR,
IOTN and ICON with respect to orthodontic treatment need and
outcome.

METHOD
A retrospective sample of 55 consecutively treated cases was identified from the orthodontic department of Middlesbrough General
Hospital. Cases were treated by clinical assistants, specialist registrars or one of three consultant orthodontists. Discontinued cases
were included in the sample.
Pre-treatment and post-treatment study models were scored
using IOTN, PAR and ICON by a calibrated examiner from another
hospital (TG). The examiner did not know which operator was
responsible for treating the case when the models were scored.
Pre- and post-treatment models were scored at random
Data analysis
Descriptive statistics were calculated to locate the central tendency and spread. Intra-examiner reliability was examined by
repeating the examination of a random subset of 15 pre-treatment and post-treatment cases. Reliability was expressed using
the weighted Kappa statistic for ordinal scores (IOTNDHC,
IOTNAC, ICON complexity). The reliability of ICON scores and
PAR were expressed using Root Mean Square to assess random
error and a Students ttest for systematic bias. The relationship
between ICON and the other indices was examined using nonparametric (Spearman) correlation.
The correlations were calculated for the pre-treatment and
post-treatment data separately.
Outcome assessment has been traditionally made by assessing
either the percentage change or absolute change in occlusal index
scores. Assessment of occlusal improvement with ICON is made by
subtracting 4x post-treatment score from the pre-treatment score,5
with the range of possible results nominally given five categories
of improvement. These five categories can be thought of as similar
in purpose to the three PAR improvement grades as determined
from the PAR nomogram.
Bivariate correlations were calculated for PAR reduction versus
ICON improvement and per cent PAR reduction versus ICON
improvement.
RESULTS
The reliability assessment of the indices is given in Tables 1a and
1b and descriptive statistics are given in Tables 2a and 2b. When
used as an ordinal scale to express treatment complexity, ICON
has marginally lower but acceptable reliability as the use of IOTN
to assign treatment need categories. When used as a quasi-continuous variable (similar to PAR) it has a similar level of precision.
Table 1a Kappa values for Intra-examiner reliability
AC

DHC

ICON

0.88
0.82
0.93

0.82
0.71
0.94

0.78
0.68
0.88

Table 2a Descriptive statistics for the entire sample with respect to IOTN
(n=55)
Index

Pre-treatment median

IOTN (AC)
IOTN (DHC)

Post-treatment median

8
4

2
2

Table 2b Descriptive statistics for the entire sample with respect to PAR and
ICON (N=55)
Index

PAR
ICON

Pre-treatment mean (S.D.)

Post-treatment mean (S.D.)

38.2 (10.6)
72.9 (13.0)

5.4 (5.9)
18.4 (7.9)

The RMS value appears to be three times higher for ICON compared with PAR. This is because the minimum score increment for
ICON is three times higher than PAR.
Table 3 shows the correlations between ICON, IOTN and PAR.
The IOTN scores suggest that the sample showed a definite need
for treatment on the grounds of dental health and aesthetics and
that the standard of treatment was good. Figure 1 shows the plot
of DHC versus ICON. For any given IOTN grade there are a range
of possible ICON scores. As expected DHC and ICON scores are
higher for pre-treatment cases. Both IOTN (DHC) and ICON classified two pre-treatment cases into the no treatment category, ie
98% of the sample justifies treatment on the grounds of dental
health as defined by the UK usage of the DHC or according to the
international standard set by ICON. Most of the post-treatment
models score an acceptable end result as defined by ICON5 ie
below 31. The poor correlation of ICON and DHC scores is related
to the limited ordinal scale of DHC with most pre-treatment cases
falling in grades 45 and post treatment 24. Many post treatment IOTN (DHC) scores were grade 4 and 3. This suggests a poor
treatment result not reflected by IOTN (AC), PAR or ICON. This is
because the study model protocol was applied and consequently
any case with any crossbite anywhere in the mouth would have to
be awarded grade 4 regardless of the size of the displacement.
Most post-treatment grade 3 IOTN (DHC) scores were due to second molars not being routinely banded. This resulted in a small
contact point displacement between first and second molars,
which meant grade 3 had to be awarded. PAR or ICON does not
pick this up.
Figure 2 shows the plot of IOTN (AC) versus ICON. For any given
IOTN (AC) grade there are a range of possible ICON scores. According
to the UK usage of IOTN (AC), 30% of this sample would not be justified for definite treatment need on the grounds of aesthetics alone (ie
an AC score of 1 to 7).
Figure 3 shows a plot of PAR score against ICON for pre- and
post-treatment study casts. It can be seen that there is a good level of
agreement between PAR and ICON.
Figure 4 compares the outcome assessment of per cent PAR
reduction with ICON improvement. Overall the relationship has a
significant (Pearson) correlation of 0.74. Approximately 55% of
the sample would be classified as greatly improved using ICON.
The mean per cent PAR reduction is 85.0 and the mean PAR
reduction is 32.8, suggesting the sample was very well treated
compared with previous UK samples and in terms of international
standards set by ICON.

Complexity

Kappa
Lower 95% confidence limit
Upper 95% confidence limit

Table 1b Differences in values for Intra-examiner reliability

Mean difference
P (t-test)
rms (random) error
226

PAR

ICON

1.6
0.086
2.33

1.83
0.588
7.9

Table 3 Spearman rank order correlation coefficients for AC, DHC and ICON
scores for pre and post treatment cases
Spearman correlations
between Indices

Pre-treatment models

ICON versus IOTN DHC

ICON versus IOTN AC
ICON versus PAR

0.17
0.64
0.51

Post-treatment models

0.46
0.86
0.36

BRITISH DENTAL JOURNAL VOLUME 193 NO. 4 AUGUST 24 2002

RESEARCH

120

Figure 1 Scatter plot of ITON (DHC)

versus ICON for pre-treatment and
post-treatment casts.

Pre-treatment
Post-treatment

A dashed line denotes treatment thresholds.

For IOTN the treatment category is for grades
4 and 5, and for ICON is any score greater
than 43. The dotted line signifies the ICON
value (31) below which a treatment can be
considered acceptable. The possible score for
DHC ranges 1 5 and 7 128 for ICON.

ICON Score

100

80

60

40

20

0
1

IOTN (DHC) Grade

Figure 2 Scatter plot of IOTN (AC)
versus ICON for pre-treatment and
post-treatment casts.

120

ICON Score

100

Pre-treatment
Post-treatment

A dashed line denotes treatment thresholds.

For IOTN (AC) the treatment category is for
grades 8 10, and for ICON is any score
greater than 43. The solid line signifies the
ICON value (31) below which a treatment can
be considered acceptable. The possible score
for AC ranges 1 10 and 7 128 for ICON.

80

60

40

20

0
0

10

IOTN (AC) Grade

Figure 3 Scatter plot of PAR versus
ICON for pre-treatment and posttreatment models.

120

100

Pre-treatment
Post-treatment

80

60

ICON

40

20

0
0

10

20

30

40

50

60

PAR
DISCUSSION
The sample used for this comparison was relatively small but reasonably diverse in as much as a fairly broad range of treatment
starts were obtained and treatment was delivered by a variety of
expert levels within the hospital service. The overall level of malocclusion is however more severe than previous estimates from the
GDS, which typically have had mean initial PAR scores of 29.9 The
sample, however, was not designed to generalise treatment outcomes in the GDS or hospital sector, but to compare the performance
of the new indices.
BRITISH DENTAL JOURNAL VOLUME 193 NO. 4 AUGUST 24 2002

Examination of Table 3 clearly shows that the degree of correlation between ICON and the other indices is influenced by the
type of models in the sample. In this hospital sample, pre-treatment cases were moderately severe and most treatments resulted
in a very minor malocclusion. For this reason a higher correlation
is obtained when comparing index scores based on the pre-treatment and post-treatment dental casts. A lower level of correlation
is reported for the assessment of treatment outcomes, probably
because the treatment results were consistently good. (If there is
little variation in a sample, poor correlations result).
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RESEARCH
Figure 4 ICON improvement
versus Percentage PAR
reduction.

100

% PAR Reduction

90
80
70
60
50
40
30
20
10

-130.00

-110.00

-90.00

-70.00

-50.00

-30.00

-10.00

10.00

30.00

50.00

70.00

Start ICON - (4 x End ICON)

The general performance of the ICON index seems to be largely
in agreement with IOTN for assessing treatment need. Although
ICON identified a higher proportion of the sample in need of treatment compared with IOTN (AC), on which it is heavily based, it did
not over score on the proportion of cases identified for treatment
on the grounds of dental health. This suggests that ICON could
probably substitute IOTN (DHC) and produce largely similar
results. An ICON score of greater than 43 reflects a definite need
for treatment.5
The general performance of the ICON index seems to be equivalent to the PAR for assessing treatment results. Both indices
identified similar proportions of the most improved cases, but
ICON overall is a more stringent standard to attain a greatly
improved categorisation. An ICON score of 31 or less defines a
clinically acceptable result.5 Like all occlusal indices, ICON will
not be appropriate in assessing need and outcome in a small
number of cases. This is certainly true of PAR.1,2,3 Its use does,
however, seem appropriate when examining a representative
sample of cases from a single practitioner or hospital department.

CONCLUSIONS
1. ICON appears able to substitute IOTN (AC) and IOTN (DHC) as
a means of measuring orthodontic treatment need. A value of
greater than 43 for ICON defines a definite need for treatment.
2. There is a close relationship between PAR score and ICON. Its
use in measuring treatment outcome appears to be as appropriate as using PAR.
3. ICON appears to require a more stringent standard than PAR
to attain a greatly improved categorisation. An ICON score of
less than 31 defines a clinically acceptable result.
The authors would like to thank Alison Downing and Lynn May, Consultant
Orthodontists at Middlesbrough General Hospital for their permission to examine
records of patients under their care, the dental nurses for their help with data
collection and Mrs M. Revelle for her help with the manuscript
2.
3.
4.
5.
6.
7.
8.
9.

228

1.Hinman C, The Dental Practice Board the current status. Br J Orth 1996; 22: 287-290.
Kerr J, Buchanan I B. The use of the PAR in assessing the effectiveness of removable
orthodontic appliances. Br J Orth 1993; 20: 351-357.
Fox N A. The first 100 cases: A personal audit of orthodontic treatment assessed by
the PAR (Peer Assessment Rating) Index. Br Dent J 1993; 174: 290-297.
Richmond S, Daniels C P, Fox N A, Wright J. The professional perception of
orthodontic treatment complexity. Br Dent J 1997; 183: 365-370.
Daniels C P, Richmond S. The development of the Index of Complexity Outcome and
Need (ICON). J Orthod 2000; 27: 149-162.
Shaw W C, Richmond S, OBrien K D, Brook P, Stephens C. Quality control in
orthodontics. Indices of treatment need and outcome. Br Dent J 1991; 170: 107-112.
Richmond S, Shaw W C, OBrien K D, et al. The development of the PAR Index (Peer
Assessment Rating) reliability and validity. Eur J Orth 1992; 14: 125-139.
Richmond S, Shaw W C, OBrien K D, et al. The relationship between IOTN and the
consensus opinion of a panel of 74 dentists. Br Dent J 1995; 178: 370-374.
Fox N A, Richmond S, Daniels C, Wright J. Factors affecting the outcome of
orthodontic treatment in the General Dental Services. Br J Orth 1997; 24: 217-21.

APPENDIX THE INDEX OF COMPLEXITY, OUTCOME AND NEED

Practical use of the index to assess treatment need
To use the index to assess treatment need the pre-treatment study
models are examined and occlusal traits are scored according to
the protocol below. The five occlusal trait scores are then multiplied by their respective weightings and summed (Table 4). If the
summary score is greater than 43, treatment is indicated.
Table 4 ICON index variables, weightings and cut-off values for treatment
need and outcome decisions
Occlusal Trait

ICON index weighting

IOTN Aesthetic
Component
Left + right
buccal
Antero-posterior
Upper arch Crowding
Overbite
Crossbite
Treatment need cut-off
Treatment outcome cut-off

7
3
5
4
5
43
31

Practical use of the index to assess treatment outcome

acceptability
To assess treatment outcome, apply the index scoring method
to the post-treatment models only. If the summary score is less
than 31 the outcome is acceptable.
Practical use of the index to assess treatment complexity
To assess treatment complexity, a five point scale is used via the
cut points for the 20 percentile intervals, using the ranges given
in Table 5 from the pre-treatment models.
Table 5 ICON index complexity cut-off values
Complexity grade

Score range

Easy
Mild
Moderate
Difficult
Very difficult

less than 29
29 to 50
51 to 63
64 to 77
greater than 77

Practical use of the index to assess the degree of improvement

To assess the degree of improvement multiply the post-treatment score by 4, and subtract the result from the pre-treatment
score. Use the ranges in Table 6 to assign a grade.
When the index is used to assess treatment outcomes, it is
assumed that an appropriate level of co-operation was obtained
from the patient. The index may require confirmation of the presence of teeth using radiography. Except for the aesthetic assessment, occlusal traits are not scored to deciduous teeth unless they
are to be retained in the permanent dentition to obviate the need
for a prosthetic replacement, for example when the permanent
tooth is absent.
The index contains five components all of which must be
scored.
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RESEARCH
premolar and lower canine and 8mm for upper canine. The presence of erupted antimeric teeth allows more accurate estimation
for this purpose. Spacing due to teeth lost to trauma and exodontia is also counted.
Post-treatment spaces created to allow prosthetic replacements
should match the antimeric tooth width. Discrepancy between such
spaces and the anitmeric tooth can be counted as excess spacing or
crowding, whichever is appropriate. The use of the index to assess
spacing in relation to retained deciduous teeth demands that the
fate of the deciduous teeth is known before the index can be
applied.
Once the raw score has been obtained it is multiplied by the
weighting 5.

Table 6 Pre-treatment 4 (Post-treatment) ICON index score ranges, for

ratings of treatment improvement
Improvement grade

Score range

greatly improved
substantially improved
moderately improved
minimally improved
not improved or worse

>-1
-25 to -1
-53 to -26
-85 to -54
<-85

Dental aesthetics
The dental aesthetic component of the IOTN6 is used. The dentition is compared with the illustrated scale and a global attractiveness match is obtained without attempting to closely match the
malocclusion to a particular picture on the scale (Fig. 5). The scale
works best in the permanent dentition.
The scale is graded from 1 for the most attractive to 10 for the
least attractive dental arrangement. Once this score is obtained it
is multiplied by the weighting of 7.

Upper arch crowding/spacing

This variable attempts to quantify the tooth to tissue discrepancy
present in the upper arch or the presence of impacted teeth in
both arches.
The sum of the mesio-distal crown diameters is compared with
the available arch circumference, mesial to the last standing
tooth on either side. This may require the use of a millimetre rule
for accuracy, but with practice can be estimated by eye with reasonable accuracy.
No estimation is made to account for the curve of Spee or the
degree of incisor inclination. Once the crowding/spacing discrepancy has been worked out in millimetres it is reduced on to the
ordinal scale using the categories shown in Table 7.
Note that an impacted tooth in either the upper or lower arch
immediately scores the maximum for crowding. A tooth must be
unerupted to be defined as impacted.
An unerupted tooth is defined as impacted under the following conditions:
1. If it is ectopically placed or impacted against an adjacent tooth
(excluding third molars but including supernumerary teeth).
2. When less than 4mm of space is available between the contact
points of the adjacent permanent teeth.

Crossbite
A normal transverse relationship in the buccal segments is
observed when the palatal cusps of the upper molar and premolar
teeth occlude preferably into the occlusal fossa of the opposing
tooth or at least between the lingual and buccal cusp tips of the
opposing tooth. Crossbite is deemed to be present if a transverse
reaction of cusp to cusp or worse exists in the buccal segment.
This includes buccal and lingual crossbites consisting of one
or more teeth with or without mandibular displacement.
In the anterior segment a tooth in crossbite is defined as an
upper incisor or canine in edge to edge or lingual occlusion.
Where a crossbite is present in the posterior or anterior segments or both, the raw score of 1 is given which is multiplied by
the weighting of 5.
Where there is no crossbite the score for this trait is zero.
Anterior vertical relationship
This trait includes both open bite (excluding developmental conditions) and deep bite. If both traits are present only the highest
scoring raw score is counted. Positive overbite is measured at the
deepest part of the overbite on incisor teeth. Scoring protocol is
given in Table 4.
Open bite may be measured with an ordinary millimetre rule to
the mid-incisal edge of the most deviant upper tooth. Multiply the
raw score obtained by 4.
Retained deciduous teeth (ie without a permanent successor)
and erupted supernumerary teeth should be scored as space unless
they are to be retained to obviate the need for prosthesis. In transitional stages average canine and premolar widths can be used to
estimate the potential crowding. Suggested averages are 7 mm for

Buccal segment antero-posterior relationship

The scoring zone includes the canine premolar and molar teeth. The
antero-posterior cuspal relationship is scored according to the protocol given in Table 7 for each side in turn. The raw scores for both
sides are added together and then multiplied by the weighting 3.
Deviation of the final score
Once all of the raw scores have been obtained and multiplied by
their respective weights, they are added together to yield a single
weighted summary score for a particular cast.

Table 7 Protocol for occlusal trait scoring

SCORE

Aesthetic

1-10 as judged using SCAN

Upper arch crowding

Score only the highest trait

either spacing or crowding

Upper spacing

<2mm

2.1mm5mm

5.19mm

9.113mm

Up to 2mm

2.1mm5mm

5.19mm

>9mm

Crossbite

Transverse relationship of
cusp to cusp or worse

No crossbite

Crossbite present

Incisor open bite

Score only the highest trait

either open bite or overbite

Complete bite

<1mm

1.1mm2mm 2.14mm

Incisor overbite

Lower incisor coverage

Up to 1/3 tooth

1/32/3 coverage

2/3 up to full
covered

Buccal segment
antero- posterior

Left and right added together Cusp to embrasure Any cusp relation up Cusp to cusp
relationship only. to but not including relationship
Class I, II or III
cusp to cusp

BRITISH DENTAL JOURNAL VOLUME 193 NO. 4 AUGUST 24 2002

13.117mm

>17mm or impacted
teeth

>4mm

Fully covered

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Figure 5 The aesthetic component of IOTN used as the first component of ICON

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