Effectiveness of Phase I Orthodontic

Treatment in an Undergraduate
Teaching Clinic
Andrew J. Bernas, D.D.S.; David W. Banting, D.D.S., Ph.D.;
Lesley L. Short, B.D.Sc., M.D.S., M.D.Sc.
Abstract: In this retrospective study, the Peer Assessment Rating (PAR) index was used to objectively evaluate the effectiveness
of Phase I (early) orthodontic treatment provided in an undergraduate teaching clinic. Pre-treatment and post-treatment casts of
ninety-three patients were analyzed. All patients selected for Phase I orthodontic treatment had Class I skeletal relationships and
did not require complex orthodontic treatment such as growth modification or treatment of occlusions with missing or impacted
teeth. The mean age of patients who received Phase I orthodontic treatment was 9.9 years. The mean initial PAR score for the
sample was 29.70 ±9.84. The mean reduction in PAR score was 14.9 points corresponding to a 50.2 percent decrease in the PAR
score following Phase I orthodontic treatment. Seventy-three percent of the patients experienced at least a 30 percent reduction in
their PAR score following Phase I (early) orthodontic treatment. The mean cost of $381.00 for the Phase I orthodontic treatment
was found to be influenced by the length of treatment, type of Phase I treatment provided, age at start of treatment, and percentage
reduction in PAR score. The greatest success rate for the Phase I orthodontic treatment occurred with either fixed or a combina-
tion of fixed and removable appliances. Over half of the patients recommended for Phase I orthodontic treatment in the under-
graduate dental clinic were successfully treated and did not require Phase II treatment. For them, there was both a treatment and
a financial benefit to the Phase I orthodontic treatment.
Dr. Bernas was a Doctor of Dental Surgery Candidate; Dr. Banting is Chair, Division of Practice Administration; and Dr. Short
is Clinical Director, Graduate Orthodontics—all at the Schulich School of Medicine & Dentistry, University of Western Ontario,
London, Ontario, Canada. Direct correspondence and requests for reprints to Dr. Lesley Short, Schulich School of Medicine
& Dentistry, Graduate Orthodontics, 1151 Richmond Street, London, Ontario N6A 5C1, Canada; 519-661-3358, ext. 86118;
519-661-3875 fax; lesley.short@schulich.uwo.ca.
Key words: orthodontics, undergraduate education, treatment outcome, PAR
Submitted for publication 2/7/07; accepted 4/12/07

O
ver the past few decades, the dental com- index is measured both as a reduction in the total
munity has become increasingly interested in score and as a percentage reduction. Richmond et
the objective analysis of treatment outcomes al.12 found that a change (reduction) greater than 30
in order to assess quality of care.1 Traditionally, percent in the weighted PAR score is required for a
orthodontic diagnosis has been considered resistant case to be considered as improved, and a reduction
to quantitative evaluation because of its subjective of at least twenty-two points is deemed to be a great
nature.2-4 The development of quantitative systems improvement. Other studies have reported that a
for assessing malocclusion and evaluating treatment change in PAR score greater or equal to 70 percent
need have been evolving for the last half of the past can be categorized as great improvement.13,14
century.5 These indices aim to provide valid systems The PAR index has become increasingly used
of measurement that are easily reproducible.6-9 in studies assessing the effectiveness of orthodontic
One such index, the Peer Assessment Rating treatment in private practices and graduate clin-
(PAR), was developed in 1990 by Richmond.10 It ics.4,14-23 A study by Birkeland et al.17 involving 224
quantifies malocclusion based on five criteria of dif- cases treated in a postgraduate clinic achieved a
ferent weightings: upper and lower anterior segment mean reduction in PAR score of 76.7 percent. These
alignment (x1), left and right buccal occlusion (x1), results were comparable to a study performed by
overjet (x6), overbite (x2), and centerline (x4). The Willems et al.16 that involved 292 cases and a study
analysis is performed on dental casts and involves a by Buchanan et al.24 that involved eighty-two cases
comparison between pre-treatment and post-treat- with mean reductions of 79.1 percent and 74 percent,
ment study models permitting the evaluation of respectively. A study by Fox25 obtained a 66 percent
treatment effectiveness in aligning teeth within and reduction using removable, fixed, and functional
between the dental arches.7,11 A change in the PAR appliances.

September 2007  ■  Journal of Dental Education 1179

 Results of orthodontic treatment outcomes instructor from China, and a full-time orthodontic
in undergraduate clinics are also available. Tolidis faculty member. Replicate measurements were per-
and Sandy15 performed a study of the effectiveness formed by all evaluators on twenty randomly selected
of orthodontic treatment over two time periods and cases to determine measurement error. The error
published PAR score reductions of 64 percent and among the three evaluators was within one point on
47 percent. In terms of Phase I or early intervention, the PAR index.
Pangrazio-Kulbersh et al.14 reported a 38 percent Information obtained for each patient included
decrease in PAR scores. the patient’s age at start of treatment, patient’s gender,
The objective of this study was to measure, by type of malocclusion, type of treatment provided,
means of the PAR index, the effectiveness of Phase need for additional orthodontic (Phase II) treatment
I orthodontic treatment performed in an undergradu- (due to relapse, incompletion of treatment, or referral
ate dental school clinic. The study also assessed the to private practice or graduate orthodontics), treat-
ability of Phase I treatment to alleviate or prevent the ment fees charged, and number of treatment episodes
need for Phase II therapy (i.e., full fixed appliance (some patients had more than one episode of Phase
comprehensive treatment) and the cost-effectiveness I treatment).
of Phase I treatment. The cost of the Phase I orthodontic treatment
was calculated in order to assess the cost-effective-
ness of the treatment. Fees were charged for diagnos-
Methods tic casts, cephalometric and panoramic radiographs,
extractions (if orthodontically related), appliances,
Cases were selected from the archives of the un- laboratory costs, and appliance adjustments. These
dergraduate Simulated Practice Environment Clinic fees reflect only the cost of the Phase I orthodontic
(SPEC), Schulich Dentistry, University of Western treatment and not the cost of all treatment provided
Ontario. The study models of 342 randomly selected to the patient in the undergraduate clinic.
patients who had received Phase I (early) orthodontic Analysis of the data was performed using de-
treatment were examined. Two hundred and forty- scriptive statistics and multiple variable regression
nine patients were excluded from the study based on models in the JMP v. statistical program. Reductions
the following reasons: there were incomplete records, in PAR scores between pre-treatment and post-treat-
the patient went directly into Phase II orthodontic ment study models were calculated both as a percent-
treatment, or the patient was too old at the start of age and as a whole number. P-values less than 0.05
treatment (over fourteen years for females and sixteen were considered to be statistically significant.
years for males). Based on these exclusion factors,
ninety-three cases were analyzed in the study.
Pre-treatment and post-treatment study mod-
els were evaluated, using the PAR index, by an
Results
undergraduate dental student, a visiting orthodontic Of the ninety-three cases selected, there were
fifty-six (60.2 percent) female patients and thirty-
seven (39.8 percent) male patients. The mean age was
Table 1. Number and percent of orthodontic problems 121.23 months (10.10 years) for female patients and
in ninety-three patients undergoing Phase I treatment 114.70 months (9.56 years) for male patients.
Orthodontic Problem N (%)
The types of orthodontic problems present in
the ninety-three patients are shown in Table 1. All
Anterior cross bite 29 (31.3%) of the cases at pre-treatment were Class I in terms
Posterior cross bite 29 (31.2%) of their skeletal relationship, although a few cases
Arch length to tooth size discrepancy 64 (68.8%)
• Crowding 44 (47.3%) were Class II or Class III with respect to their dental
• Spacing (including midline diastema) 24 (25.8%) relationship.
Vertical discrepanciesa 17 (18.3%) The majority of patients in this study (68.8
Otherb 18 (19.4%) percent) had an arch length to tooth size discrepancy.
Total 157*
The most common treatment modality provided was
a
Deep bite and open bite partial fixed appliances (41 percent). The distribution
b
Habit correction and midline deviations of treatment modalities used during Phase I treatment
*Some patients had more than one problem.
is presented in Figure 1.

1180 Journal of Dental Education ■ Volume 71, Number 9

Figure 1. Percent of Phase I orthodontic treatment provided by treatment type
a
Expansion appliances include both slow palatal expansion (removable) and rapid palatal expansion (fixed) appliances.
b
Active removable appliances not involving expansion.

The mean pre-treatment PAR score was 29.71 score reduction is accounted for by the length of
±9.84, and that score dropped to a mean of 14.80 the Phase I treatment (Figure 3). The mean percent
±9.46 following Phase I treatment. This represents reduction in PAR scores by type of treatment used
an average 50.2 percent reduction in the PAR score. in the Phase I treatment ranged from 41.6 percent to
The mean length of treatment was 16.30 ±11.78 51.8 percent. There was no statistically significant
months with a range of three to fifty-nine months, and difference found among the mean percent reduction
the mean cost of the Phase I treatment was $380.79 in PAR scores attributed to the different types of
±$186.66 with a range of $65.00 to $1,131.50. Phase I treatment provided (p=0.92).
Seventy-five percent of the patients underwent A multiple regression model revealed that the
a single episode of Phase I treatment, while the post-treatment PAR score was significantly influ-
remainder (25 percent) had two or more episodes enced by the pre-treatment PAR score (p=0.002)
(three patients had three episodes of Phase I treat- and the length of the treatment (p=0.02). But there
ment). Based on the nomogram in Figure 2, a reduc- was also a significant interaction term between the
tion (improvement) in PAR score ≥30 percent was pre-treatment PAR score and the length of the Phase
shown in sixty-eight cases (73.1 percent). Twenty-six I treatment (p=0.01), indicating that the effect of the
patients (28.0 percent) had a reduction in their PAR pre-treatment PAR score and the length of treatment
scores ≥70 percent, qualifying them as being greatly on the post-treatment PAR score must be interpreted
improved following Phase I treatment. Twenty-five with caution. The type of treatment, multiple treat-
patients (26.9 percent) either showed no difference or ment episodes, and age at start of treatment were
a deterioration in their PAR scores. Additional (Phase not significant predictors of the post-treatment PAR
II) treatment was recommended for 47.3 percent of score.
the patients (Table 2). Both III Year (junior) and IV Similarly, a multiple variable regression model
Year (senior) students provided the Phase I treatment showed that the length of treatment (p=0.003), the
under supervision. age at start of treatment (p=0.04), the treatment
A positive but low (r=0.24, R2=0.06) correla- type (p=0.007), and the percent PAR score change
tion was found between the percent reduction in the (p=0.006) were all statistically significant variables
PAR score and the length of the treatment. Longer for predicting the cost of treatment. Gender and
treatment resulted in slightly greater PAR score the pre-treatment PAR score were not statistically
reductions; however, very little of the percent PAR significant explanatory variables for predicting cost

September 2007  ■  Journal of Dental Education 1181

 Figure 2. Nomogram illustrating pre-treatment and post-treatment PAR scores in terms of degree of improvement

Table 2. Number and percent of patients recommended for Phase II treatment following Phase I treatment by type of
Phase I treatment
Type of Phase I Treatment Provided Number of Patients Number and Percent of Patients
Completing Phase I Treatment Recommended for Phase II Treatment

Expansiona 17 12 (70.6%)
Expansiona and fixed 9 6 (66.7%)
Fixed only 38 12 (31.6%)
Removable only 18 10 (55.6%)
Removableb and fixed 11 4 (36.4%)
Overall 93 44 (47.3%)
a
Expansion appliances include both slow palatal expansion (removable) and rapid palatal expansion (fixed) appliances.
b
Active removable appliances not involving expansion.

of treatment. No interaction terms were used. This

model was able to account for 35.2 percent of the Discussion
variability in the cost of Phase I treatment.
Phase I (early) orthodontic treatment is advo-
The mean fees for the various Phase I treat-
cated for several types of orofacial problems ranging
ment modalities of treatment are presented in Table
from simple space management to more complicated
3. Treatment involving partial fixed appliances was
problems requiring skeletal and dental changes.
the most expensive, especially when combined with
In this study, only Phase I orthodontic treatment
other treatment types. The total fee charged for the
provided in a dental school undergraduate clinic
Phase I treatment was shown to correlate positively
was investigated. This study did not look at Phase I
(r=0.36, R2=0.13) with the percent reduction in PAR
treatment associated with skeletal malocclusions or
score (Figure 4).
complicated dental malocclusions.

1182 Journal of Dental Education ■ Volume 71, Number 9

Figure 3. Percent change (reduction) in PAR score by length of treatment (r=0.24, R2=0.06)

Over half (53 percent) of the sample did not these considerations, complete reduction of PAR is
continue on to Phase II treatment because an adequate not expected in Phase I. Another explanation for these
outcome was achieved with Phase I treatment. This results is that the cases selected in the undergraduate
finding is encouraging as it is rare for a malocclusion clinic are uncomplicated. Patients treated are skeletal
to improve without orthodontic intervention.14,26,27 It Class I with only mild to moderate malocclusions.
should be remembered that Phase I treatment is con- Thus, another explanation for the limited reduction
siderably less expensive than Phase II treatment. in PAR for this group could be the low initial PAR
The mean percentage change (reduction) in scores, thereby making it more difficult to achieve a
PAR score in this study was lower than
studies assessing Phase II or compre-
hensive treatment.1,4,17,24,28 However, this
study agreed with a study by Pangrazio- Table 3. Mean cost of Phase I treatment by type of treatment
Kulbersh et al. that assessed Phase I Type of Phase I Treatment Mean Cost Standard Deviation
treatment.14 This suggests that the degree
Expansiona and fixed $503.72 204.39
of improvement in PAR score is reflec- Removableb and fixed $485.32 195.09
tive of the phase of treatment assessed. Expansiona only $307.29 150.02
Phase I (early or limited treatment) is Fixed only $386.49 192.23
not necessarily designed to finish the Removableb only $312.83 139.54
Overall $380.79
occlusion but to address major concerns
of the malocclusion that are noted early, a
Expansion appliances include both slow palatal expansion (removable) and
thereby alleviating the need for compre- rapid palatal expansion (fixed) appliances.
b
Active removable appliances not involving expansion.
hensive orthodontic treatment. Given

September 2007  ■  Journal of Dental Education 1183

 Figure 4. Percent change (reduction) in PAR score by cost of treatment (r=0.36, R2=0.13)

more substantial percent reduction in the PAR score treated with removable appliances initially were
as noted by other authors.5,14,24 recommended to continue with either further Phase I
The sample (n=93) was comprised of 60 or Phase II treatment. Therefore, based on the results
percent females and 40 percent males. This gender of this study, removable appliances are not gener-
distribution is similar to that reported in other stud- ally able to completely address Phase I orthodontic
ies.15,29,30 The age at the start of treatment (mean 9.9 treatment needs. Apart from mechanical inefficiency,
years) indicates that, generally, skeletal growth is still other possible explanations for this finding are poor
occurring in these patients.14,24,25,31 patient compliance and appliance failure. These fea-
Since there was a positive association between tures are more common with removable appliances
the cost of Phase I orthodontic treatment and both than with fixed appliances. Fixed appliances are gen-
the percentage change in PAR scores and the amount erally more efficient because compliance and failure
of reduction in PAR scores, it would appear that the are more easily managed, which appears to translate
more money that is spent, the better the result that can into less need for additional episodes of treatment.
be expected. However, the model used to predict the In comparison, only about 30 percent of patients who
cost of Phase I orthodontic treatment was only able received partial fixed appliances initially in Phase I
to account for or explain a small proportion of the treatment required further Phase I or Phase II cor-
variability in the fees charged. Thus, there are likely rection. Our study also showed that when expansion
other parameters that were not included in this study is included in Phase I treatment, the need for further
that may influence the overall fee to the patient (e.g., treatment (either Phase I or II) is high (70 percent).
diagnostic skills of the clinician). This may reflect the increased difficulty of manage-
While removable appliances were shown to be ment of lateral deficiencies.
less expensive than the other treatment modalities, There is a lack of consensus among orthodon-
nearly 40 percent of patients who received removable tists as to different treatment modalities during Phase
appliances had to combine their treatment with partial I treatment.14 This study did not show any differences
fixed appliances because the removable appliance between treatment modalities in terms of PAR score
alone was unable to complete the Phase I treatment. reduction. This finding has been demonstrated pre-
Furthermore, approximately 56 percent of patients viously14 and may reflect the ability of orthodontists

1184 Journal of Dental Education ■ Volume 71, Number 9

to arrive at a similar result using different methods. • the proper selection of cases for Phase I orth-
Further studies analyzing the way different treatment odontic treatment is critical to the success of the
modalities influence the different components of the treatment.
PAR score may reveal whether one treatment mode
is more efficient at correcting a specific malocclu- Acknowledgments
sion, even though the overall change in PAR may We would sincerely like to thank Dr. Sara
be similar. There is also a lack of consensus among Shamloo for her expertise in the application of PAR
orthodontists regarding the need for Phase I treatment score analysis, Dr. Fernando Inocencio for the use of
at all.32,33 If Phase I treatment is sufficient to correct a computer, Dr. Lihua Shan for her assistance with
the malocclusion, it can be financially beneficial. data collection, and Dr. Sahza Hatibovic-Kofman
This study showed that over half the cases treated in and the secretarial staffs of Graduate Orthodontics,
this undergraduate clinic enjoyed this benefit. How- SPEC, and Main Clinic for all their assistance and
ever, nearly half of the cases in this study required support during this project.
Phase II treatment, raising the possibility that Phase
II (comprehensive treatment) alone may have been
able to address all treatment needs in a single episode
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