SPECIAL ARTICLE

The ABO discrepancy index: A measure of

case complexity
Thomas J. Cangialosi, DDS,a Michael L. Riolo, DDS, MS,b S. Ed Owens, Jr, DDS, MSD,c Vance J. Dykhouse,
DDS, MS,d Allen H. Moffitt, DMD, MSD,d John E. Grubb, DDS, MSD,d Peter M. Greco, DMD,d Jeryl D.
English, DDS, MS,d and R. Don James, DDS, MSDe
New York, NY, Grand Haven, Mich, Jackson, Wyo, Blue Springs, Mo, Murray, Ky, Chula Vista, Calif, Philadelphia, Pa,
Houston, Tex, and Oklahoma City, Okla

A criterion for determining the acceptability of a case presented for the American Board of Orthodontics
(ABO) Phase III clinical examination is case difficulty. Case difficulty can often be subjective; however, it is
related to case complexity, which can be quantifiable. Over the past 5 years, the ABO has developed and
field-tested a discrepancy index, made up of various clinical entities that are measurable and have generally
accepted norms. These entities summarize the clinical features of a patient’s condition with a quantifiable,
objective list of target disorders that represent the common elements of an orthodontic diagnosis: overjet,
overbite, anterior open bite, lateral open bite, crowding, occlusion, lingual posterior crossbite, buccal
posterior crossbite, ANB angle, IMPA, and SN-GoGn angle. The greater the number of these conditions in
a patient, the greater the complexity and the greater the challenge to the orthodontist. The ABO is
considering several options for applying the discrepancy index to the Phase III clinical examination. (Am J
Orthod Dentofacial Orthop 2004;125:270-8)

A
criterion for determining the acceptability of a and to benchmark and measure specific treatment skills
case submitted for the American Board of that are typical clinical challenges encountered by the
Orthodontics (ABO) Phase III clinical exami- orthodontic specialist.
nation is case complexity. Case complexity is defined This DI method of case analysis is the ABO’s
as “a combination of factors, symptoms, or signs of a current approach to summarizing the clinical features of
disease or disorder which forms a syndrome.”1 There- a patient’s condition with a quantifiable, objective list
fore, the ABO has devised the Discrepancy Index (DI) of target disorders that represent common problems
to provide an objective evaluation of complexity that associated with orthodontic diagnosis.
might lead to a better understanding of difficulty. The
DI is an objective method to describe the complexity of HISTORY
the treatment for a patient based on observations and
measurements taken from standard pretreatment ortho- The DI was initially developed in 1998 at a meeting
dontic records, including casts and cephalometric and of the 8 ABO directors and 6 former directors who were
panoramic radiographs. then serving as consultants to the ABO. During the
Additionally, the DI was developed to create an 1999 Phase III examination, 100 cases submitted by
alternative to the ABO case category requirements or candidates were scored for discrepancy by 2 directors,
possibly to supplement but not entirely replace them.2 and this data provided the initial pilot study of the DI.
The rationale for this was to offer a broader basis to Based on these results and the discussion that followed,
qualify cases for the ABO Phase III clinical examina- the DI was modified, and additional field tests and data
tion. The case categories3-9 were created to help estab- analyses were performed at the 2000, 2001, 2002, and
lish target disorder10 baselines for case presentations 2003 examinations, with all directors and examiners
scoring every case for discrepancy.
a
President of the ABO. In addition, in 2002, candidates were asked to score
b
President-elect of the ABO. their optional cases (categories 9 and 10) for discrep-
c
Secretary-treasurer of the ABO. ancies and, in 2003, were asked to score all the cases
d
Director of the ABO.
e
Past president of the ABO. they presented. Based on these field tests, additional
Reprint requests to: Thomas J. Cangialosi, Columbia University, School of modifications were made to the DI, and candidate/
Dentistry, 630 W 168th St, New York, NY 10032; e-mail, tjc1@[Link]. examiner calibration was assessed. The results of these
0889-5406/$30.00
Copyright © 2004 by the American Association of Orthodontists. field tests are summarized in Figures 1 and 2. The
doi:10.1016/[Link].2004.01.005 results of the field tests show that 3 categories—5, 6,
270
American Journal of Orthodontics and Dentofacial Orthopedics Cangialosi et al 271
Volume 125, Number 3

Fig 1. DI ranges.

Fig 2. DI ranges.
272 Cangialosi et al American Journal of Orthodontics and Dentofacial Orthopedics
March 2004

Fig 3. Occlusal relationship position.

Fig 4. Overjet.

Fig 5. Overbite.

and 7— have higher discrepancy scores, and categories available so that other conditions that might affect or
1, 2, 3, 4, 8, 9, and 10 show moderate to lower add to treatment complexity can be scored. When
discrepancy scores. scoring discrepancy, model occlusion (Fig 3) is deter-
The target disorder elements chosen to make up the mined by placing the backs (bases) of models on a flat
DI are measurements of overjet, overbite, anterior surface after they have been placed together in occlu-
openbite, lateral openbite, crowding, occlusion, lingual sion. All measurements must be made from this occlu-
posterior crossbite, buccal posterior crossbite, ANB sal relation position. A description of each measure-
angle, IMPA and SN-GoGn angle. ment follows.
An additional category designated “Other” is also Overjet (Fig 4) is scored as the distance between the
American Journal of Orthodontics and Dentofacial Orthopedics Cangialosi et al 273
Volume 125, Number 3

Fig 6. Anterior open bite.

Fig 7. Lateral open bite.

Fig 8. Crowding.

lingual incisal edge of the most forwardly positioned and if greater than 9 mm, 5 points are scored. If there
maxillary incisor to the labial incisal edge of the is a negative overjet (anterior crossbite), the score is
most forwardly positioned mandibular incisor. For recorded as 1 point per mm for each anterior tooth in
an overjet of 0 mm (edge to edge), 1 point is scored; crossbite.
for overjets of 1-3 mm, no points are scored; for 3.1 For an overbite (Fig 5) up to 3 mm, no points are
to 5 mm, 2 points are scored; for 5.1 to 7 mm, 3 scored. If the overbite is 3.1-5 mm, 2 points are scored;
points are scored; for 7.1-9 mm, 4 points are scored, if it is 5.1-7 mm, 3 points are scored. If the mandibular
274 Cangialosi et al American Journal of Orthodontics and Dentofacial Orthopedics
March 2004

Fig 9. Occlusion.

Fig 10. Lingual posterior crossbite. Fig 11. Buccal posterior crossbite.

incisors are impinging on the palatal tissue (100% dental arch is considered. If crowding is 1-3 mm, 1
overbite), then 5 points are scored. point is scored; from 3.1-5 mm, 2 points are scored;
For anterior open bite, if the maxillary and mandib- from 5.1-7mm, 4 points are scored, and if greater than
ular incisors are in an edge-to-edge relationship (over- 7 mm, 7 points are scored.
bite ⫽ 0), then 1 point is scored. For each millimeter of When scoring occlusion (Fig 9), the Angle clas-
openbite, 2 points are scored for each maxillary tooth sification is used. If the mesiobuccal cusp of the
involved from canine to canine. No points are scored maxillary first molar occludes with the buccal groove
for the maxillary canines if they are blocked out of the of the mandibular first molar or anywhere forward of
arch to the labial (Fig 6). the buccal groove but short of the mesiobuccal cusp,
For lateral open bite, for each maxillary tooth (from no points are scored. If the occlusal relationship is
first premolar to third molar) in an open bite relation- end on (cusp to cusp) toward a Class II or Class III
ship with the mandibular arch, 2 points are scored per but less than a Class II or Class III relationship, 2
millimeter of open bite for each tooth (Fig 7). points are scored per side. If the relationship is a full
When scoring crowding (Fig 8), the most crowded Class II or Class III, then 4 points are scored per side.
American Journal of Orthodontics and Dentofacial Orthopedics Cangialosi et al 275
Volume 125, Number 3

Fig 12. Cephalometric values.

Fig 13. Congenital absence. Fig 14. Ectopic eruption.

If the relationship is greater or beyond Class II or Procedures for scoring skeletal or dental
Class III, then 1 additional point is scored per side. relationships that increase case complexity based
For lingual posterior crossbite, for each maxillary on cephalometrics
tooth in lingual crossbite, 1 point is scored (Fig 10). 1. If the ANB angle is greater than 5.5° or less than
For each maxillary posterior tooth in complete ⫺1.5°, 4 points are scored. For each additional
buccal crossbite, from first premolar to third molar, 2 degree above or below these values, 1 point is
points are scored (Fig 11). scored.
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March 2004

Fig 15. Transposition.

2. If the SN-GoGn angle is between 27° and 37°, no an index, the “other” category permits the scoring of
points are scored. other commonly occurring conditions. An additional 2
3. If the SN-GoGn angle is greater than 37°, then 2 points can be scored for each of the following: missing
points are scored for each degree above 37°. or supernumerary teeth (Fig 13), ectopic eruption (Fig
4. If the SN-GoGn angle is less than 27°, then 1 point 14), transposition (Fig 15), anomalies of tooth size and
is scored for each degree below 27°. shape, CR-CO discrepancies, skeletal asymmetry, ex-
5. If the IMPA angle is greater than 98°, 1 point is cess curve of Wilson. Each “Other” condition scored
scored for each degree above 98°. must be noted on the scoring sheet (Fig 16).
The following is an example of a cephalometric DISCUSSION
grading sequence (Fig 12).
The target disorders of which this index is com-
SNA 76.0° prised were chosen because they represent most condi-
SNB 69.0° tions that orthodontists treat. They were also chosen
ANB 7.0°: 5 points scored because all could be related to deviations from gener-
SN- GoGn 37.0°: no points scored ally accepted norms. Another consideration was that
IMPA 105.0°: 7 points scored the DI measurements could be done relatively quickly
and simply.
Other Do these measurements equal difficulty? Difficulty
Because it is impossible to include every clinical is elusive because inherently it remains somewhat
entity that might contribute to treatment complexity in subjective and a matter of perception. Some conditions
American Journal of Orthodontics and Dentofacial Orthopedics Cangialosi et al 277
Volume 125, Number 3

Fig 16. DI scoring sheet.

278 Cangialosi et al American Journal of Orthodontics and Dentofacial Orthopedics
March 2004

that are considered difficult by some orthodontists alternative to case categories is to provide a broader
might be perceived as relatively easy to treat by others. basis for cases to qualify for the Phase III examination.
This might be due to differences in overall approach to The ABO will continue to closely monitor the
treatment, differences in appliances or appliance de- results of this and future field tests. The DI will no
sign, or differences in training. However, most clini- doubt continue to contribute to the overall objectivity of
cians will agree that the greater the number of target the Phase III examination and be available to make
disorders, the greater the complexity of the case. For candidates aware of what is expected of them as they
this reason the term discrepancy, rather than difficulty prepare for their examination. The tools that the ABO
index, has been used. has developed to evaluate cases presented for certifica-
Over the years, indexes11-13 have been developed tion are also meant to be a mechanism for self-
primarily to assess treatment need. Generally, when assessment for orthodontists; this can lead to improve-
using these indexes, a threshold is set, and cases must ment over the life span of a practice.
reach that threshold to set the priority for treatment To make the certification process as clear and open
need. This did not serve the ABO’s purpose, which was as possible, the ABO will continue to publish articles
not to determine treatment need but to develop a that shed light on the examination process to help
method to assist in the selecting cases for the Phase III prepare candidates for an examination that will remain
examination that was related to the complexity of fair and comprehensive. A video disk presentation
treatment. describing the DI will be available in the ABO office
Some indexes are also used to evaluate the outcome soon.
of treatment by measurements made before and after
We thank the Cadent Corporation, the producer of
treatment. Although the score of the target disorders
Orthocad models; Geodigm Corporation, the producer
might be reduced to near zero after treatment, the case
of e-models; and Orthodontic Processing, the producer
would still have to meet the requirements of a finished
of QuickCeph Systems for their assistance in providing
occlusion according to the ABO cast and panoramic
images for this manuscript. We also thank Dr Richard
radiograph grading system.14,15 Therefore, how can the
Diemer for the statistical analysis of the field tests.
DI be used?
After 5 years of field testing and with feedback REFERENCES
from the orthodontic educational community and other
1. Online dictionary. Available from: [Link]
members of the specialty, the ABO is considering how Accessed 7/2/2003.
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Several possibilities have emerged. It could be used to 7/2/2003.
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As of this writing, the ABO has decided to offer the DI 6. Information for candidates. 4th ed. St Louis: ABO; 1998.
as an alternative to case category requirements for the 7. Information for candidates. 4th ed. St Louis: ABO; July 1997.
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Based on these statistics, the requirement for using 12. Salzmann JA. Handicapping malocclusion assessment to estab-
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