A new Norwegian inijex of orthoijontic treatment neeij related to orthodontic concern among 11 -year-olds and their parents
Lisen V. Espeland, Knut Ivarsson and Arild Stenvik Department of Orthodontics, University ot Oslo Norway '
Espeland LV, Ivarsson K, Stenvik A; A new Norwegian index of orthodontie treattnent need related to orthodontic eoneern among 11-year-olds and their paretits. Community Dent Oral Epidetniol 1992; 20: 274 9. Abstraet - A new index of orthodontie treattnent need was introduced in Norway in 1990. On a tnorphologic atid futictional basis the four groups very great (A), great (B), obvious (C) and little/no (D) need were defined for social insurance refunding. The purpose of the present study was to investigate to what extent the new index eoriesponded with orthodontie eoneern among potential orthodontic patients and their parents. Of 104 randomly seleeted fourth grade ehildren, 99 (48 girls, 51 boys, mean age 10.7 yr) presented themselves for clinieal examination and interview. One parent was asked to accompany the ehild, and 93 parents attended. On the basis of clinical examination, morphologic measurements on study casts, and X-rays, the ehildren were allocated to one of the four groups defined by the index. In separate questionnaires the children and the parents were asked lo assess satisfaetion with own/child's dental arrangement and desire for orthodontie treatment. The interview data were transformed into a eomposite measure representing orthodontie concern. The results indieated thai orthodontie concern was significantly related to index group. For the individuals who expressed eoneern the new index seemed to be meaningful for allocation of publie subsidies, as most individuals (85%) who expressed eoneern exhibited tnaloeclusions fulfilling the criteria for receiving publie subsidies of treatinent costs. However, more than 5O'y;i of the individuals allocated to group B (great need) did not experienee a need for treatment.
Several indiees have been developed with the objeet of standardizing evaluation of maloeelusion for the assesstnent of orthodontic treatment need. Indiees of tteatment need have limited value for piescription of individual treatment tneasures, but tnay be useful for administrative and public health purposes (1). Of partieular interest has been the establishment of treatment priority for the provision of publie funded orthodontie eare and systetnatie allocation of treattnent resources. Most indices are designed to express severity of malocclusion quantitatively based oti prolessiotial criteria (2 6). The validity of indiees has been diseussed by CARLOS (7), and a major problem is measuring the aesthetie or psyehosocial iinpairmeni of malocclusion in a way that is meaningful to the professional, the individual, and the public. In one study eight orthodontic indices were re-
lated to self perception of dental aestheties (8). The ability of all eight indiees to distinguish individuals who were satisfied with their dental appeatanee frotn those who were not, was weak. Concern about appearanee is a major faetor inllueneing patients" pereeived need for treattnent (9- I 1). Attetnpts have been made to develop tnethods lor measuring dental aestheties (12, 13) and to establish standards that represent socially aeeeptable dental appearanee (14). A tiew British itidex has both a dental health cotnponent and a separate aesthetie component (15). Fxperimentiil sludies have demonstrated a discrepaney between lay and professional judgments of dental aestheties and need for treatment (16, 17). Some investigators have, on the other hand, eoneluded that societal and professional norms for aeeeptable dental appearanee parallel eaeh other (12, 18).
Key words: malocclusion: treatment need index: psychosocial need L. V. Espeland. Department of Orthodontics, University of Osio, Geitmyrsveien 71, 0455 Oslo Norway Accepted for publication 7 November 1991
In Norway a new orthodontie treatment need index was introdueed in 1990 for alloeation of tefunds of Ireatnient eosts by the Natiotial llealth Insurance System (19). As national subsidies for orthodontic eare are limited, the treattnent eosts are reimbursed by the governtnent in aeeordance with the severity of tnaloeelusioti. The index defines four groups or grades, denoting very great need, great tieed, obvious need, and little/no need (100, 75, 40 and 0% reinibutsetnent, respeetively). Traits presutned to be assoeiated with concern for dental appearanee and to eause psychosocial problems were incorporated in the index, although based solely on professional estimates. The purpose ofthe present study was to investigate whether the new index correlated with concern for dental appearanee in potential orthodontic patients and their parents.
Treatment need iiii/e.x and orthodontic concern
Subjects and methods
Fourth grade children attending three public schools iti different aresa of the city of Dranitncn, Norway, were invited by letter to participate in the study with one of their parents. Of 104 tandomly selected famihes, 99 ehildren (48 girls, 51 boys, mean age 10.7 yr) and 93 aeeompanying parents (82 mothers, II fathers) presented themselves al a public dental clinic I'or a elinical exatnination of the child and an iutei view of both the child and the parent. Impressions for dental study easts were taken of all the ehildren. Orthodontie treatment had been planned or recently itiilialed in 12 ofthe children. Three of these children were not accompanied by a parent.
Treatment need index group
The variotts dentofaeial conditions and morphologic trails that constitute the four groups of the tieatment need index are given below. Selection of traits and defltiitions of cut-off points are based on present scientific evidence and empirieal orthodontic norms about the risks for dentrimental effects of dentofaeial anomalies on dental heallh, function and psychosoeial well-being. Group A: Very great need 1. Cleft lip-jaw-palale 2. Inherited or acquired eraniofacial atiomalies 3. Severe anomalies requiring a combination of orthodontics and orthognathie surgery 4. Anomalies of comparable severity Group B: Great need \. Overjet 9 mm or more 2. Unilateral buecal or lingual erossbite o n three or more pairs of opposing teelh with forced bite and/or asymmetry 3. Anterior open bite with oeclusal eontacts on molars only 4. Impacted ineisors atid canines where appliance therapy is neeessaiy 5. Anterior erossbite on all ineisors 6. Anterior teeth missing due to agetiesia or tooth loss 7. Increased overbite (deep bile) with labial or palatal inipingenient ofthe soft tissue with two or more teeth 8. Bilateral bueeal ctossbite (scissors
bite) on two or more pairs of opposing teeth 9. Agenesis of two or more teeth in the same quadrant (3rd molars excepted) U). Anomalies of eornparable severity Group C: Ohviou.f ticed 1. Overjet 6-9 tiim 2. Open bile on three or more pairs of opposing teelh 3. Inversion of anterior leeth 4. Ineteased overbite (deep bite) without contact on anterior leeth, or with eontaet on the gingival 1 /4 of the palatal surface of the maxillary anterior teeth 5. Agenesis of single teeth in the lateral segmetiis 6. Median diastema of 3 tiitn or more, or pronounced general spacing of anterior segnietit 7. Pronounced crowding of anterior teeth 8. Oeelusal disorder eombined with strong subjective dysfunetion symptotns 9. Anomalies of eonipatable severity
275
The morphologic measurements and the grouping of the ehildren were performed by two examiners. Disagreements on classification of individuals were identified, and the final allocation to an index group was deterruined after joint reevaluation. Repealed reeoidings were made by one of the examiners 1 month later frotn the eolleeted records.
Orthodontic concern (psychosocial treatment need)
Information on satisfaction with dental appearanee and desire for treatment was obtained from interviews of the ehildren and the parents. Two separate questionnaires were administered, a child form and a parent form. The questions, which had four fixed alternative answers, were adapted from other studies (8. 20. 21). The questions on the ehild form were; ".Are you .satisfied with the arrangement ()/'i'(;;/r/ c
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ous need) with no orthodontic concern This category teptescnted a substantial proportion of the individuals: two Ihirds of group C and one thitd of Ihe total satnple. Maloeckisiotis allocated to group C may teptesetit a botderlitie decision atid constitute a dilemnia for Uig professional advisot\ Cotnpared to group B the treatment indications are weaker and the risk-cost-beneftt relationship les^ obvious. Generally the patient's and patents' |ierceptioiis of the impairtnent will be decisive for treatment rcconi... tnendatiotis. Individuals who do tioi po-, ccivc a need will generally be left untreated. The third category of divetgeney be~ tweeii index group and orthodotitie concern iticluded only a few individuals (4% of the presetit sample), those who perceived a need despite presence of only minor irregularities (group D). Information to the patient and the patents about aspects of trcattiient inputs atid outcomes may produce a shift in their attitudes. As an example, two of the actual individuals exptessed concern for labially eruptinij canines that would most probably coi-I rect spontaneously with titiie. According to the index two thirds of the children were assessed to be in great or obvious need of tieattnent (groups B and C). When the eoneern for treattnent was taken into accotint. the treattnent need could be estitnated to be about 35% This figure reptesents all the childten in group B and (hose in group C who express concern. This fiequency corresponds fairly well to the proportion of childteti who have received tieattnent over Ihe last two decades in Norway (19), In conclusion, most individuals (85%) exptessing concern exhibited malocclusiotis fulfillitig the criteria for receiving public stibsidies of tieatinent expenses. For these itidividuals the new treattnctit need index appeared to be meaningful. U may. however, he questioned if the index is cotnpreheiisiblc to all the unconcerned individuals. According to the index, about two thirds of the investigated subjects fulfilled the tequitements to receive public subsidies, atid otily about one third acttially utidetgo treatment. The findings indicate that treattnent tieed indices should be subject to periodic revision and possible adjtisttnetits according to new knowledge. Such research should comprise investigations on soeictal standards for aeceptable dental appearance.
Treatinent need index and orthodontie concern Acknowledgments Tlic aulhor.s wish lo acknowledge Cliief 15ciilal OITicer TURID ALBUM ALSTAD and her slalT for assistance in collecti n g the material
References 1. Hl-I.M S. Reappraisal of the criteria fur orthodontie treatmenl. Thesis. Universily of Oslo, 1990. 2. DRAKI'R HL. Handicapping labio-lingual deviations: a piopo.sed inde.\ lor public health purposes. Am .1 Orthod IQdO; 46: 295 305. 3. GRAiN(it;R RM. Orthodontie treatment priority itidex. Public Health Service Public. No 1000 Ser 2, NO 25, Washington, D.C: LI.S. Governtnent Printing Office, 1967. 4 . SALZMANN JA. Handicapping malocclusion assessment to establisli treiittnent priority. /(/M ,/ Chthod 19(i8; 54: 749-65. 5. SUMMI:RS CJ. The occlusal index: a system for identifying and scoring occlti.sal disorders. Am ./ Orttiod 1971; 59: 552 67. 6. LuNDSTROM A. Need for treattnent in cases of tiialocclusion. Trans Eur Orthod Soe 1977; 53: 111 23. 7. CARLOS JP. Hvaluatioti of indices of malocclusion. //(/ Denl .1 1970; 20: 606 17. 8. KATZ RV. Relationships between eight orthodontic indices and an oral self-itiiagc satisfaction scale. Am .1 Orttiod 1978; 73: 328-34. 9. Al.ntNO JH, CuNAr JJ, l*i« RN, Li;wis EA, St.AKTiiR MJ, Tl:i:)i:sro LA. Variables discriminating individuals who seek orthodontic treattnent. ./ Dent Res 1981; 60: 1661-7. 10. Tin.i.ocii ,II-"C, SHAW WC, SMtTH A, J(INI:S G, JONES M . A compari.son of attitudes toward orthodontic tteatment in British
and American communities. .-!/» ,/ Orthod 1984; ,V.5.- 253 9. 11. GosNtiV MBF. An investigation into some o^ the factors inllviencing the desire for orthodontic treatment. Br J Orlhod 1986; yi.- 87 94. 12. Tl!i:)HSCO LA, ALiitNO JE, CIINAT JJ, CiRtitiN Ll, LEWIS EA. St.AKiHR MJ. A dental-faeial attractiveness seale. Part 1. Reliability and validity. Am .1 Orthod 1983; /. 38 43. 13. EVANS R . SHAW WC. Preliminary evalua-
21. HtiLM S, PtiTERSLN PE, KktltBORG S, SoLow B. Effect of separate malocclusion traits on concern for dental appearance. C(m»ii»Mirv Denl Oral Epidemiot 1986; 14: 217 20. 22. CoHt;N J. A coefficient of agreement for tiominal scales. Edue Psyctiol Mea.sureiiient 1960; 20: 37-46. 23. LANt:)ts JR, Koru GG. The measurement of observer agreement for categorical data. Biometrics 1977; ,«.• 159-74. 24. ATKtN.soN RL, ATKINSON RC, SMtTH EE,
tion of an illustrated scale for tating dental attractiveness. Fur .1 Orthod 1987; 9: 314 8. 14. Jt:NNY J, CONS NC, KOHOUT FJ, FRAZttiR
15. 16. 17.
18.
19. 20.
PJ. Test of :i method to determine socially acceptable occlusal cotuiitions. Community Dent Oral Fpidemiol 1980; S: 424 ^^. BROOK PH, SttAW WC. The development of an index of orthodontic treatment priority. Fur .1 Orthod 1989; //.• 309 20. SitAW WC, Li;wis HG, ROIII:RTSON NRi:. Pereeption of tnalocclusion. Br Dent ./ 1975; 138: 211 6. PtiAHt.-ANf)i:t
Lisen V. Espeland, Knut Ivarsson and Arild Stenvik Department of Orthodontics, University ot Oslo Norway '
Espeland LV, Ivarsson K, Stenvik A; A new Norwegian index of orthodontie treattnent need related to orthodontic eoneern among 11-year-olds and their paretits. Community Dent Oral Epidetniol 1992; 20: 274 9. Abstraet - A new index of orthodontie treattnent need was introduced in Norway in 1990. On a tnorphologic atid futictional basis the four groups very great (A), great (B), obvious (C) and little/no (D) need were defined for social insurance refunding. The purpose of the present study was to investigate to what extent the new index eoriesponded with orthodontie eoneern among potential orthodontic patients and their parents. Of 104 randomly seleeted fourth grade ehildren, 99 (48 girls, 51 boys, mean age 10.7 yr) presented themselves for clinieal examination and interview. One parent was asked to accompany the ehild, and 93 parents attended. On the basis of clinical examination, morphologic measurements on study casts, and X-rays, the ehildren were allocated to one of the four groups defined by the index. In separate questionnaires the children and the parents were asked lo assess satisfaetion with own/child's dental arrangement and desire for orthodontie treatment. The interview data were transformed into a eomposite measure representing orthodontie concern. The results indieated thai orthodontie concern was significantly related to index group. For the individuals who expressed eoneern the new index seemed to be meaningful for allocation of publie subsidies, as most individuals (85%) who expressed eoneern exhibited tnaloeclusions fulfilling the criteria for receiving publie subsidies of treatinent costs. However, more than 5O'y;i of the individuals allocated to group B (great need) did not experienee a need for treatment.
Several indiees have been developed with the objeet of standardizing evaluation of maloeelusion for the assesstnent of orthodontic treatment need. Indiees of tteatment need have limited value for piescription of individual treatment tneasures, but tnay be useful for administrative and public health purposes (1). Of partieular interest has been the establishment of treatment priority for the provision of publie funded orthodontie eare and systetnatie allocation of treattnent resources. Most indices are designed to express severity of malocclusion quantitatively based oti prolessiotial criteria (2 6). The validity of indiees has been diseussed by CARLOS (7), and a major problem is measuring the aesthetie or psyehosocial iinpairmeni of malocclusion in a way that is meaningful to the professional, the individual, and the public. In one study eight orthodontic indices were re-
lated to self perception of dental aestheties (8). The ability of all eight indiees to distinguish individuals who were satisfied with their dental appeatanee frotn those who were not, was weak. Concern about appearanee is a major faetor inllueneing patients" pereeived need for treattnent (9- I 1). Attetnpts have been made to develop tnethods lor measuring dental aestheties (12, 13) and to establish standards that represent socially aeeeptable dental appearanee (14). A tiew British itidex has both a dental health cotnponent and a separate aesthetie component (15). Fxperimentiil sludies have demonstrated a discrepaney between lay and professional judgments of dental aestheties and need for treatment (16, 17). Some investigators have, on the other hand, eoneluded that societal and professional norms for aeeeptable dental appearanee parallel eaeh other (12, 18).
Key words: malocclusion: treatment need index: psychosocial need L. V. Espeland. Department of Orthodontics, University of Osio, Geitmyrsveien 71, 0455 Oslo Norway Accepted for publication 7 November 1991
In Norway a new orthodontie treatment need index was introdueed in 1990 for alloeation of tefunds of Ireatnient eosts by the Natiotial llealth Insurance System (19). As national subsidies for orthodontic eare are limited, the treattnent eosts are reimbursed by the governtnent in aeeordance with the severity of tnaloeelusioti. The index defines four groups or grades, denoting very great need, great tieed, obvious need, and little/no need (100, 75, 40 and 0% reinibutsetnent, respeetively). Traits presutned to be assoeiated with concern for dental appearanee and to eause psychosocial problems were incorporated in the index, although based solely on professional estimates. The purpose ofthe present study was to investigate whether the new index correlated with concern for dental appearanee in potential orthodontic patients and their parents.
Treatment need iiii/e.x and orthodontic concern
Subjects and methods
Fourth grade children attending three public schools iti different aresa of the city of Dranitncn, Norway, were invited by letter to participate in the study with one of their parents. Of 104 tandomly selected famihes, 99 ehildren (48 girls, 51 boys, mean age 10.7 yr) and 93 aeeompanying parents (82 mothers, II fathers) presented themselves al a public dental clinic I'or a elinical exatnination of the child and an iutei view of both the child and the parent. Impressions for dental study easts were taken of all the ehildren. Orthodontie treatment had been planned or recently itiilialed in 12 ofthe children. Three of these children were not accompanied by a parent.
Treatment need index group
The variotts dentofaeial conditions and morphologic trails that constitute the four groups of the tieatment need index are given below. Selection of traits and defltiitions of cut-off points are based on present scientific evidence and empirieal orthodontic norms about the risks for dentrimental effects of dentofaeial anomalies on dental heallh, function and psychosoeial well-being. Group A: Very great need 1. Cleft lip-jaw-palale 2. Inherited or acquired eraniofacial atiomalies 3. Severe anomalies requiring a combination of orthodontics and orthognathie surgery 4. Anomalies of comparable severity Group B: Great need \. Overjet 9 mm or more 2. Unilateral buecal or lingual erossbite o n three or more pairs of opposing teelh with forced bite and/or asymmetry 3. Anterior open bite with oeclusal eontacts on molars only 4. Impacted ineisors atid canines where appliance therapy is neeessaiy 5. Anterior erossbite on all ineisors 6. Anterior teeth missing due to agetiesia or tooth loss 7. Increased overbite (deep bile) with labial or palatal inipingenient ofthe soft tissue with two or more teeth 8. Bilateral bueeal ctossbite (scissors
bite) on two or more pairs of opposing teeth 9. Agenesis of two or more teeth in the same quadrant (3rd molars excepted) U). Anomalies of eornparable severity Group C: Ohviou.f ticed 1. Overjet 6-9 tiim 2. Open bile on three or more pairs of opposing teelh 3. Inversion of anterior leeth 4. Ineteased overbite (deep bite) without contact on anterior leeth, or with eontaet on the gingival 1 /4 of the palatal surface of the maxillary anterior teeth 5. Agenesis of single teeth in the lateral segmetiis 6. Median diastema of 3 tiitn or more, or pronounced general spacing of anterior segnietit 7. Pronounced crowding of anterior teeth 8. Oeelusal disorder eombined with strong subjective dysfunetion symptotns 9. Anomalies of eonipatable severity
275
The morphologic measurements and the grouping of the ehildren were performed by two examiners. Disagreements on classification of individuals were identified, and the final allocation to an index group was deterruined after joint reevaluation. Repealed reeoidings were made by one of the examiners 1 month later frotn the eolleeted records.
Orthodontic concern (psychosocial treatment need)
Information on satisfaction with dental appearanee and desire for treatment was obtained from interviews of the ehildren and the parents. Two separate questionnaires were administered, a child form and a parent form. The questions, which had four fixed alternative answers, were adapted from other studies (8. 20. 21). The questions on the ehild form were; ".Are you .satisfied with the arrangement ()/'i'(;;/r/ c
2
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B B
a
U
15
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278
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ous need) with no orthodontic concern This category teptescnted a substantial proportion of the individuals: two Ihirds of group C and one thitd of Ihe total satnple. Maloeckisiotis allocated to group C may teptesetit a botderlitie decision atid constitute a dilemnia for Uig professional advisot\ Cotnpared to group B the treatment indications are weaker and the risk-cost-beneftt relationship les^ obvious. Generally the patient's and patents' |ierceptioiis of the impairtnent will be decisive for treatment rcconi... tnendatiotis. Individuals who do tioi po-, ccivc a need will generally be left untreated. The third category of divetgeney be~ tweeii index group and orthodotitie concern iticluded only a few individuals (4% of the presetit sample), those who perceived a need despite presence of only minor irregularities (group D). Information to the patient and the patents about aspects of trcattiient inputs atid outcomes may produce a shift in their attitudes. As an example, two of the actual individuals exptessed concern for labially eruptinij canines that would most probably coi-I rect spontaneously with titiie. According to the index two thirds of the children were assessed to be in great or obvious need of tieattnent (groups B and C). When the eoneern for treattnent was taken into accotint. the treattnent need could be estitnated to be about 35% This figure reptesents all the childten in group B and (hose in group C who express concern. This fiequency corresponds fairly well to the proportion of childteti who have received tieattnent over Ihe last two decades in Norway (19), In conclusion, most individuals (85%) exptessing concern exhibited malocclusiotis fulfillitig the criteria for receiving public stibsidies of tieatinent expenses. For these itidividuals the new treattnctit need index appeared to be meaningful. U may. however, he questioned if the index is cotnpreheiisiblc to all the unconcerned individuals. According to the index, about two thirds of the investigated subjects fulfilled the tequitements to receive public subsidies, atid otily about one third acttially utidetgo treatment. The findings indicate that treattnent tieed indices should be subject to periodic revision and possible adjtisttnetits according to new knowledge. Such research should comprise investigations on soeictal standards for aeceptable dental appearance.
Treatinent need index and orthodontie concern Acknowledgments Tlic aulhor.s wish lo acknowledge Cliief 15ciilal OITicer TURID ALBUM ALSTAD and her slalT for assistance in collecti n g the material
References 1. Hl-I.M S. Reappraisal of the criteria fur orthodontie treatmenl. Thesis. Universily of Oslo, 1990. 2. DRAKI'R HL. Handicapping labio-lingual deviations: a piopo.sed inde.\ lor public health purposes. Am .1 Orthod IQdO; 46: 295 305. 3. GRAiN(it;R RM. Orthodontie treatment priority itidex. Public Health Service Public. No 1000 Ser 2, NO 25, Washington, D.C: LI.S. Governtnent Printing Office, 1967. 4 . SALZMANN JA. Handicapping malocclusion assessment to establisli treiittnent priority. /(/M ,/ Chthod 19(i8; 54: 749-65. 5. SUMMI:RS CJ. The occlusal index: a system for identifying and scoring occlti.sal disorders. Am ./ Orttiod 1971; 59: 552 67. 6. LuNDSTROM A. Need for treattnent in cases of tiialocclusion. Trans Eur Orthod Soe 1977; 53: 111 23. 7. CARLOS JP. Hvaluatioti of indices of malocclusion. //(/ Denl .1 1970; 20: 606 17. 8. KATZ RV. Relationships between eight orthodontic indices and an oral self-itiiagc satisfaction scale. Am .1 Orttiod 1978; 73: 328-34. 9. Al.ntNO JH, CuNAr JJ, l*i« RN, Li;wis EA, St.AKTiiR MJ, Tl:i:)i:sro LA. Variables discriminating individuals who seek orthodontic treattnent. ./ Dent Res 1981; 60: 1661-7. 10. Tin.i.ocii ,II-"C, SHAW WC, SMtTH A, J(INI:S G, JONES M . A compari.son of attitudes toward orthodontic tteatment in British
and American communities. .-!/» ,/ Orthod 1984; ,V.5.- 253 9. 11. GosNtiV MBF. An investigation into some o^ the factors inllviencing the desire for orthodontic treatment. Br J Orlhod 1986; yi.- 87 94. 12. Tl!i:)HSCO LA, ALiitNO JE, CIINAT JJ, CiRtitiN Ll, LEWIS EA. St.AKiHR MJ. A dental-faeial attractiveness seale. Part 1. Reliability and validity. Am .1 Orthod 1983; /. 38 43. 13. EVANS R . SHAW WC. Preliminary evalua-
21. HtiLM S, PtiTERSLN PE, KktltBORG S, SoLow B. Effect of separate malocclusion traits on concern for dental appearance. C(m»ii»Mirv Denl Oral Epidemiot 1986; 14: 217 20. 22. CoHt;N J. A coefficient of agreement for tiominal scales. Edue Psyctiol Mea.sureiiient 1960; 20: 37-46. 23. LANt:)ts JR, Koru GG. The measurement of observer agreement for categorical data. Biometrics 1977; ,«.• 159-74. 24. ATKtN.soN RL, ATKINSON RC, SMtTH EE,
tion of an illustrated scale for tating dental attractiveness. Fur .1 Orthod 1987; 9: 314 8. 14. Jt:NNY J, CONS NC, KOHOUT FJ, FRAZttiR
15. 16. 17.
18.
19. 20.
PJ. Test of :i method to determine socially acceptable occlusal cotuiitions. Community Dent Oral Fpidemiol 1980; S: 424 ^^. BROOK PH, SttAW WC. The development of an index of orthodontic treatment priority. Fur .1 Orthod 1989; //.• 309 20. SitAW WC, Li;wis HG, ROIII:RTSON NRi:. Pereeption of tnalocclusion. Br Dent ./ 1975; 138: 211 6. PtiAHt.-ANf)i:t
