https://doi.org/10.15218/edj.2018.

14

Assessment of the Removable Orthodontic Treatment

Outcome Using Peer Assessment Rating Index
Mohammed Hussain Saleh(1); Omar F. Chawshli(2); Rebin Ali Mohammed Amin(3)

Background and objectives: Removable orthodontic appliances are useful in a variety of

situations but present the inherent disadvantage of the treatment being in the control of
the patient. Evaluation of orthodontic treatment result, aids to establish aims and reach a
measurable finish for completed treatment for patients. In order to study the quality of
treatment, it is advisable to assess the results of treatments. To achieve this aim, an
accepted index is required to assess the occlusion and the positions of teeth in the arch.
Peer Assessment Rating (PAR) is a typical mean to evaluate the result of orthodontic
treatments. The aim of the study is to assess the results of orthodontic treatments by
removable appliances on the basis of PAR index.
Patients and methods: Treatment of patients has been done by dental students by using
removable orthodontic appliances, therefore the dental study casts of 64 consecutively
completed removable appliance cases were examined before and after orthodontic
treatment using the PAR index.
Results: On the basis of weighted PAR criteria, the difference between scores before and
after treatment was significant for anterior maxillary segment (P<0.001), overjet (P<0.001),
overbite (P<0.001), midline (P<0.001), buccal occlusion in transverse and anteroposterior
direction (P<0.01). On the other hand, a non-significant difference was recorded regarding
buccal occlusion in vertical sections (P=0.99).
Conclusion: The average of PAR index reduction was higher in girls than in boys. The proper
selection of cases for Phase I orthodontic treatment is critical to the success of the
treatment. Removable orthodontic appliances are useful for correction of minor
abnormalities, especially in anterior region.

Keywords: PAR index, Outcome assessment, Orthodontic treatment.

(1)
B.D.S., M. Sc., Assistant Lecturer at the College of Dentistry- Hawler Medical University.
(2)
B.D.S., M. Sc., Ph.D., Assistant Professor at the College of Dentistry- Hawler Medical University.
(3)
B.D.S., M. Sc., Assistant Lecturer at the College of Dentistry- Hawler Medical University.

Introduction
Removable appliances are the appliances that can be removed by the patient
without any supervision by the orthodontist. Removable orthodontic appliances are
useful in a variety of situations but present the inherent disadvantage of the treatment
being in the control of the patient.1
Evaluation of the orthodontic treatment result aids to establish aims, to set
standards and to reach a measurable finish for completed treatment for patients. Also,
it is helpful for educational reasons for postgraduate orthodontic programs. Usually,
evaluation of orthodontic treatment has been done by using the subjective estimation
and knowledge of the clinician.2

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In order to study the quality of treatment, it preventive dentistry at the College of

is advisable to assess the results of treatments. Dentistry - Hawler Medical University, on the
To achieve this aim, an accepted index is basis of PAR index.
required to assess the occlusion and the
positions of teeth in the arch. Peer Assessment Patients and methods
Rating (PAR) is a typical mean to evaluate A cross-sectional study carried out at the
results of orthodontic treatments.3 The PAR department of pedodontics, orthodontics and
index is increasingly used in studies assessing preventive dentistry, College of Dentistry -
the effectiveness of orthodontic treatment in Hawler Medical University. The pre- and post-
private practices and graduate clinics.4-8 The treatment records, including orthodontic files
PAR index is considered specifically for the and study casts of 64 consecutively finished
evaluation of treatment results. The PAR cases representing different malocclusion
index affords a single summary score for all categories, were evaluated by authors. The
the occlusal anomalies which may be found in inclusion criteria adopted were: patients who
a malocclusion.9 received complete orthodontic treatment at the
It quantifies malocclusion based on five orthodontic clinic in the College of Dentistry
criteria of different weightings: upper and and the availability of pre- and post-treatment
lower anterior segment alignment (x1), left records (orthodontic casts and files,).
and right buccal occlusion (x1), overjet (x6), Exclusion criteria were retreatment cases (i: e,
overbite (x2), and centerline (x4). The analysis treatment after relapse). Both pre- and post-
is performed on dental casts and involves a treatment weighted PAR scores were
comparison between pre-treatment and post- calculated according to British weightings
treatment study models permitting the system, by a single author who was calibrated
evaluation of treatment effectiveness in in the use of PAR index. Each upper and
aligning teeth within and between the dental lower dental cast was measured as separate
arches,10 and in occlusion according to the criteria of
There are two methods for evaluating PAR index using PAR index ruler (Figure 1).
improvement of treatment by using the PAR The data were recorded on a data sheet
index, either reduction in the weighted PAR specially designed for the study.
score or percentage reduction in the weighted
PAR score. It has been recommended that a
good standard of orthodontic treatment should
result in a mean PAR reduction of 70% or
more.11
Unfortunately, due to variation in the criteria
which is used by different orthodontists, it is
difficult to match results of treatment. So it is
essential to accurately assess whether a
valuable enhancement has been achieved in
terms of overall alignment and occlusion for a
single patient and a larger proportion of a
practitioner’s caseload.11
The purpose of this study is to assess the
results of orthodontic treatments by removable Figure 1: PAR index ruler was used to make
appliances performed by dental students in the measurements easier.
department of pedodontics, orthodontics and

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Descriptive statistics including means, improved”, “improved” and “worse or no

standard deviations and ranges were calculated different” based on PAR score reduction.9
for pre-treatment PAR score, post-treatment Occlusion parts were evaluated before and
PAR score, and reduction in PAR score. The after treatment on the basis of PAR index.
PAR scores were calculated at the PAR index has 11 parts which include:
pretreatment stage and at the end of active anterior mandibular segment, right and left
treatment. Points reduction and percentage posterior mandibular segments, overjet,
reduction in the weighted PAR score was overbite, midline, right and left buccal
calculated to assess the improvement in occlusion. For each part, a specific scoring has
malocclusion at the end of treatment. Cases been determined (Figure 2).11
were divided into three categories; “Greatly

Figure 2: PAR scoring sheet used to record 11 parts of study on dental casts.

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After measurements and giving a specific for pair comparisons. P-values less than 0.05
score to each part, the scores added to each were considered to be statistically significant.
other and raw data scores were achieved. But
since the total scores were not sufficient for Results
the evaluation of occlusion improvement and On the basis of weighted PAR criteria, the
standard treatment, the other points had been difference between scores before and after
considered as PAR index was measured for treatment was significant for anterior
each model and weighted according to criteria maxillary segment (P<0.001), overjet
of Richmond et al.11 (P<0.001), overbite (P<0.001) and midline
The grades achieved for each segment of (P<0.001), buccal occlusion in transverse and
occlusion were multiplied by the related antero-posterior section (P=0.01). On the other
coefficient and the final result is found for hand, a non-significant difference was
each segment. These figures were added recorded regarding buccal occlusion in vertical
together and called weighted PAR criteria. sections (P=0.99) (Table 1, 2 and 3). The
After 4 weeks, intra- and inter examiner difference between the total scores of PAR
calculation was re-performed on 15 randomly- index before and after treatment was
selected dental casts by estimating Pearson significant (P<0.001). Total average of
correlation coefficient. Results showed decreased percentage of PAR index was
excellent reliability. At the end, the data calculated as 56.6% (Table 4). Also, on the
analyzed on the basis of our goals in order to basis of the current study, 9.37% of samples
evaluate treatment success. Data analysis was had “with no difference or worse” grades,
done by means of SPSS software. The applied 71.87% had “improvement” grade and 18.75%
test for analysis was Wilcoxon signed rank test had “complete improvement” grade.

Table 1: Evaluation of removable orthodontic treatment according to Peer Assessment Rating indexes.

Orthodontic treatment

Score of PAR Weighted PAR

degree degree
All degree before degree after P value
before after
Scores
Mean ( SD) Mean (SD) Mean (SD) Mean (SD)

Anterior maxillary
4.578(1.88) 1.75(1.6) 1 4.57(1.88) 1.75(1.6) < 0.001
segment
Ant-post 0.75(1.41) 0.4375(1.1) 1 0.75( 1.41) 0.4375(1.1) 0.01

Trans Buccal 0.5625(1.45) 0.25(1.1) 1 0.56(1.45) 0.25(1.1) 0.01

Vertical 0.03125(0.17) 0 1 0.03(0.17) 0 0.99

Over jet 1(1.13) 0.375(0.6) 6 6 (8.16) 2.22(3.6) <0.001

Over bite 0.7188(1.14) 0.4688(0.94) 2 1.42(2.28) .92(1.88) < 0.001

Center line 0.25(0.50) 0.1667(0.37) 4 1(2) 0.64(1.48) < 0.001

Total 7.891(1.55) 3.438(0.57) 16 14.31(2.28) 6.21(0.81) < 0.001

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Table 2: Evaluation of removable orthodontic treatment according to Peer Assessment Rating indexes for female
patients.

Orthodontic treatment

Score of PAR Weighted PAR

Female degree degree
degree before degree after P Value
before after
Scores
Mean ( SD) Mean (SD) Mean (SD) Mean (SD)
Anterior maxillary
4.51(1.43) 1.93(1.32) 1 4.51(1.43) 1.93(1.32) < 0.001
segment
Ant-post 0.67(1.25) 0.4(.85) 1 0.67(1.25) 0.4(.85) 0.01

Trans Buccal 0.59(.89) 0.29(1.19) 1 0.59(.89) 0.29(1.19) 0.01

Vertical 0.034(.27) 0 1 0.034(.27) 0 0.99

Over jet 1.05(.97) 0.32(0.88) 6 6.03(5.82) 1.92(5.28) <0.001

Over bite 0.59(1.32) 0.38(.67) 2 1.18(2.64) .76(1.34) < 0.001

Center line 0.22(.43) 0.18(.45) 4 0.44(.86) .72( 1.8) < 0.001

Total 7.7(1.48) 3.52(.96) 16 13.45(2.34) 6.02(1.14) < 0.001

Table 3: Evaluation of removable orthodontic treatment according to Peer Assessment Rating indexes for male
patients.

Orthodontic treatment
Score of PAR Weighted PAR
Male degree degree
degree before degree after P Value
before after
Scores
Mean ( SD) Mean (SD) Mean (SD) Mean (SD)
Anterior maxillary
4.63 (1.26) 1.57(1.34) 1 4.63 (1.26) 1.57(1.34) < 0.001
segment
Ant-post 0.83(.94) 0.46(.57) 1 0.83(.94) 0.46(.57) 0.01
Trans Buccal 0.53(1.24) 0.21(.87) 1 0.53(1.24) 0.21(.87) 0.01
Vertical .026(.14) 0 1 .026(.14) 0 0.99
Over jet .95(1.04) 0.42(.95) 6 5.7(6.24) 2.52(5.7) <0.001
Over bite .83(1.32) 0.54(1.12) 2 1.66(2.64) 1.08(2.24) < 0.001
Center line .28(.56) 0.14(.43) 4 1.12(2.24) .56(1.72) < 0.001
Total 8.076(1.34) 3.34(.46) 16 14.49(2.37) 6.4(0.78) < 0.001

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Table 4: Amount of decreased percentage of weighted PAR index after removable orthodontic treatment.

Amount of decrease
Criteria
percentage mean (SD)
Anterior maxillary segment 61.7 (4.8)
Ant-post 41.66 (14.43)
Trans 55.35 (23.94)
Vertical 0 (0)
Over jet 63(35.43)
Over bite 35.21 (22.71)
Center line 36 (21.26)
Total 56.6 (36.48)

Discussion maxillary segment, and midline. Total PAR

Since PAR index offers a specific score to indices showed a significant difference before
any parameter in occlusion; it can be used to and after removable orthodontic treatment
assess different types of malocclusions and (P<0.001) and weighted PAR index decrease
treatments. The degree of improvement and percentage was 34.07%. Also, 38.6% of
success of treatment is settled by comparing samples had “with no difference or worse”
PAR index scores before and after orthodontic grade, 57.1% had “improvement” grade which
treatment. In the current study, different is less than the current study, and 4.3% had
occlusion segments of 64 orthodontic patients “complete improvement” grade which is less
(32 girls and 32 boys) were examined. The than the current study.3 This represents an
results showed that there was significant a average 50.2% reduction in the PAR score
difference in PAR scores of the anterior which is less than the current study. The
maxillary segment, overjet and overbite and current study showed better results compared
midline, but PAR scores had no significant to Abtahi’s study.
difference in the cases of posterior occlusion One of the reasons for the better results, may
before and after treatment. The degree of be due to the age of the patients, as our
improvement was more in boys than girls with patients were younger, so the chance of faster
non-significant difference. tooth movement is possible. Another reason
In the current study, treatment of patients for better treatment result for the current study
had been done by dental students by using is that most of the cases were class I
removable orthodontic appliances; therefore, malocclusion, while Abtahi (2009) used class
achieving lower percentage for PAR index II cases more. However, both studies showed
decrease was expected. It is interesting to significant improvement after treatment. In the
know that only 9.37% of those patients were Abtahi (2009) study, PAR index decreased
placed in “with no difference of worse” group. percentages for girls and boys were 42.39 
According to a study done by Abtahi (2009), 34.7% and 54.2  19.38% respectively. In
the results showed that there was a significant Alyami’s study, PAR index decreased
difference in PAR scores of right buccal percentages were 69.4  25.9% for girls and
occlusion, overjet, and overbite and PAR 68.2  26.31% for boys. In the current study,
scores had no significant difference in the PAR index decreased percentages for girls and
cases of left buccal occlusion, anterior

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boys were 54.77 % and 58.43 % treatment. As removable orthodontic

respectively. This difference can be due to the appliances are used for tipping and rotation
difference of devices used in these studies. movements and depend on patient compliance,
According to Kerr’s study (1993), in which so lower percentage of reduction is expected
removable appliances were used for compared to fixed appliances.
treatments, 89% of samples had
“improvement” grade and 16% had “with no Conflicts of interest
difference or worse” grade3 which shows The authors reported no conflicts of interest.
better result than the current study. It seems
that in this study, patient selection was done References
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