with the ever increasing importance of clinical effectiveness , audit and quality assurance ; it is becoming mandatory to grade one 's own treatment results .
the idea of individuals grading their own performance is a self - teaching exercise and improves the quality of future treatment .
the assessment of orthodontic treatment needs and the outcome has traditionally been accomplished using subjective opinion and the experiences of clinicians . however , the variations in criteria used by different orthodontists and lack of reproducibility are limitations of the subjective evaluation . visual analog scale ( vas )
has been the most widely used as a subjective assessment method for the validation of various indices . in early surveys , various classifications were used as determinants of treatment needs and outcome . however , various authors such as massler and frankel , drakers , bjoerk et al . , and summers devised indices to evaluate malocclusion on the basis of objective requirements of occlusal discrepancies .
pickering and vig were the first to investigate the use of summers occlusal index as objective grading version to assess the outcome of treatment .
devised peer assessment rating ( par ) indices to evaluate malocclusion on the basis of objective requirements of occlusal discrepancies .
the american board of orthodontics ( abo ) model grading system is presently one of the most detailed scoring systems in use .
comprehensive clinical evaluation as outcome assessment was developed which included facial form , dental esthetics , vertical control , arch form , periodontium management , root structure preservation , and treatment efficiency . to assess clinical performance , both objective and
although there are many studies in the literature mentioning the orthodontic treatment outcome of various bracket systems , various extraction pattern , various bracket slot size , type of orthodontic practice , that is , private versus university practice , timing of treatment ; and general practitioner versus orthodontist but , to our knowledge , there are very few studies in the literature mentioning the effect of assessment of treatment outcome on the orthodontic treatment outcome .
thus , the present study was conducted to find out the role of posttreatment critical evaluation ( ptce ) implementation on the effect of orthodontic treatment outcome . to eliminate any institutional bias ,
the study sample comprised of pretreatment and post treatment orthodontic records of 235 consecutively debonded cases in the department of orthodontics , oral health sciences centre , postgraduate institute of medical education and research , chandigarh .
cases whose orthodontic treatment was completed during the period 1999 and 2004 were included in phase - i ( n = 109 ) evaluation .
a total of 278 cases were debonded during this period , out of which 120 cases comprised of compromised debond and incomplete records and 49 cases comprised of cleft and surgical cases .
cases whose orthodontic treatment was completed during the period 2006 and 2010 were included in phase - ii ( 126 ) evaluation .
the sample was extracted from a total of 328 debonded cases , out of which 108 comprised of cleft and surgical cases , 94 had incomplete records .
while selecting a case for the evaluation , no attempt was made to select a case on the basis of malocclusion type , gender or extraction pattern .
orthodontic cases having good quality pretreatment and posttreatment records such as study models , photographs , and orthopantomograms ( opgs ) ; and orthodontic cases those had completed comprehensive orthodontic treatment in both the arches were included in the study .
orthodontic cases having good quality pre - treatment and post - treatment records like study models , photographs and orthopantomograms and orthodontic cases those had completed comprehensive orthodontic treatment in both the arches were included in the study . in order to improve the quality of orthodontic care , ptce of each case
was made mandatory as a part of the clinical protocol after phase - i study .
the power point presentation contained detailed pre and post treatment records which included study models , intraoral and extra - oral photographs , intraoral periapical radiographs , opg , lateral cephalograms .
detailed history , progress of treatment , number of missing appointments , data from study model , opg and lateral cephalometric analysis and abo model grading , superimpositions of pretreatment , stage , and post - treatment cephalograms ( to evaluate growth , change in facial profile and incisor molar positions ) were also included in the power point presentation . during the presentation ,
pre- and post - treatment records , data and treatment plan were critically evaluated by all the postgraduate residents and faculty .
the presence of any lacunae in the treatment was discussed , and special emphasis was given to improve these lacunae subsequently .
then , 6-years after implementation of compulsory ptce for each case , the orthodontic treatment outcome of all consecutively debonded cases was evaluated ( phase - ii ) .
the treatment outcome was evaluated by american board of orthodontics model grading system ( abo mgs ) and subjective evaluation .
the abo model grading system included eight criteria to measure the post - treatment finishing of the occlusion .
post - treatment study models and panoramic radiographs were scored by one examiner for eight components of the abo mgs using the abo measuring gauge .
the intraexaminer calibration was done by repeated abo scoring by the examiner at the interval of 4 weeks . as per the abo instruction ,
a case with < 20 points would pass , and the case with 30 points would fail . a case with points more than 20 but
thus , the scores were thus divided into three categories , that is , grade - i ( score 020 points ) , grade - ii ( score 2030 points ) , and grade - iii ( score > 30 points ) .
the subjective evaluation was carried out by three external examiners who were senior orthodontists with a minimum of 7 years of clinical experience and also involved in orthodontic teaching .
the external examiners were chosen to avoid any bias in scoring cases from one 's own department .
each of the three examiners judged debonded cases independently at different time periods for treatment outcome based on combined assessment of the pre- and post - treatment dental casts and photographs ( extraoral and intraoral , pre- and post - treatment photographs ) .
the mean of the vas score allotted for each case by the three examiners was calculated for the purpose of analyzing the results .
the scale used was 11-point ( 010 ; 0 = very poor , and 10 = excellent ) vas , which was anchored at its two ends with extreme limits of very poor and excellent .
the total vas score was divided into three grades , that is , poor ( vas score 04.9 ) , fair ( vas score 56.9 ) , and good ( vas score 710 ) . the treatment outcome of cases in phase - i and phase - ii evaluation were noted on a standard performa .
the mean values with standard deviation for the individual components and the total abo score of the abo model grading system for the total sample was recorded .
the mean of the vas score allotted for each case by the three examiners was calculated for the purpose of analyzing the results .
the statistical analysis was carried out using spss - software version-16.0 ( spss inc . released 2007 .
the intra examiner reliability was determined among the various components of the abo mgs and the total score by using paired t - test and pearson 's correlation coefficient .
the cronbach 's alpha test was used to determine the intraexaminer reliability for each of the three examiners .
unpaired t - test was used to compare various components and a total score of abo model grading system and subjective evaluation between phase - i and phase - ii .
the chi - square test was used for comparison between phase - i and phase - ii for different categories of abo model grading and subjective evaluation .
the statistical analysis was carried out using spss - software version-16.0 ( spss inc . released 2007 .
the intra examiner reliability was determined among the various components of the abo mgs and the total score by using paired t - test and pearson 's correlation coefficient .
the cronbach 's alpha test was used to determine the intraexaminer reliability for each of the three examiners .
unpaired t - test was used to compare various components and a total score of abo model grading system and subjective evaluation between phase - i and phase - ii .
the chi - square test was used for comparison between phase - i and phase - ii for different categories of abo model grading and subjective evaluation .
the intra examiner reliability among the various components of the abo mgs and the total score was found to be between 0.888 and 1 .
the description of cases evaluated during the phase - i and phase - ii evaluation is summarized in table 1 .
description of cases evaluated during phase - i and phase - ii evaluation the mean value for the individual components of the abo mgs and the total abo score for the total sample in phase - i and phase - ii evaluation is described in table 2 .
the mean scores of alignment , marginal ridge relationship , occlusal contacts , and interproximal contacts were improved in phase - ii evaluation as compared to phase - i evaluation ; and the difference was comparable .
the buccolingual inclination , occlusal relationship , and root angulation were improved significantly during phase - ii evaluation ( p < 0.001 ) . the score for overjet
was improved from phase - i evaluation to the phase - ii evaluation ( p < 0.01 ) .
the total abo score was improved significantly from 30.06  10.54 at phase - i evaluation to the 26.67  7.77 at phase - ii evaluation ( p < 0.01 ) .
the mean values for the individual components of the abo mgs and the total abo score for the total sample in phase - i and phase - ii evaluation and their comparison the distribution of the sample according to abo score during phase - i and phase - ii evaluation is described in table 3 .
the percentage of cases in the grade - i of abo category was similar during phase - i and phase - ii evaluation ( 20.10% vs. 20.63% ) .
the percentage of cases in the grade - ii of abo category was improved significantly from phase - i evaluation ( 34.03% ) to phase - ii evaluation ( 50.79% ) ( p < 0.01 ) .
the percentage of cases in the grade - iii of abo category was decreased significantly during phase - ii evaluation ( 45.87% ) as compared to the phase - i evaluation ( 28.57% ) ( p < 0.01 ) .
comparison of total number of cases falling in each category of abo model grading system between phase - i and phase - ii evaluation the value of reliability for three examiners was found as 0.675 that indicated the good reliability between the examiners .
the vas score for the total samples evaluated in phase - i and phase - ii is described in table 4 .
the mean vas score for the total sample was improved from 5.66  0.77 at phase - i to 6.02  0.99 during phase - ii .
the percentage of cases in the poor and fair grades was decreased from phase - i evaluation to the phase - ii evaluation .
the percentage of cases scoring good score was increased significantly from 7.34% at phase - i evaluation to 19.05% at phase - ii evaluation indicating improvement in the orthodontic treatment outcome ( p < 0.01 ) .
comparison of mean vas score and total number of cases falling in each category of vas grading between phase - i and phase - ii evaluation
the excellence in finishing and the quality displayed at the end of orthodontic treatment constitutes a fundamental goal of orthodontic specialty . during all stages of treatment
, one should keep the end results in mind , providing a protected occlusion , better aesthetics ( both dental and facial ) , good periodontal health and long - term stability , which are correlated to proper finishing .
the sample for the study was collected from the records available in the department for a large sample in order to draw generalized conclusions .
the gender distribution was not considered while including a case for the study because of uneven distribution of males and females .
all the cases were evaluated by the same observer and the intraexaminer reliability value was found as 0.985 , which was > 0.85 recommended by abo members .
the results of the present study showed a reduction in the mean total abo score from 30.06  10.54 to 26.67  7.77 .
there was an improvement in the score of each component of abo model grading system .
the cases falling in the grade - ii category had also been increased from 33.03% to 50.79% from the phase - i evaluation to phase - ii evaluation .
the implementation of compulsory ptce was responsible for the improvement in the treatment outcome at phase - ii evaluation .
the average total abo score ( 26.67 ) that we observed at the end of phase - ii evaluation was less than the average score of 45.54  18.33 for university group of illinois and 33.88 for abo group .
the results of the present study correspond with the study done in indiana university school of dentistry .
the better results in our study could be secondary to the implementation of compulsory ptce for orthodontic residents .
we also considered a subjective assessment by three external orthodontists to compare the overall treatment outcome and treatment quality . in the subjective evaluation , not only
study models were evaluated , but also intraoral and extraoral photographs were evaluated to identify the improvement in the profile . as the scoring on the vas was totally based on the personal opinion and judgment of the external examiners , this evaluation was purely subjective in nature and no standardization in terms of any set criteria or guidelines was carried out .
therefore , an absolutely independent judgment was done by removing the confounding bias related to a discussion among the examiners .
similar to abo model grading scores , the vas score was also improved at phase - ii evaluation , and the implementation of compulsory ptce was responsible for such improvement . however , unlike abo model grading system , the subjective evaluation scored the treatment results by looking at the change in occlusion , as well as facial appearance , thus it did not have the inherent limitation of objective indices .
the lack of any objective measures to determine the results explained the low reliability of subjective criteria .
similarly , to our study low reliability values were also reported by richmond et al .
, where they used a 9-point scale for subjective assessment of dental casts with respect to deviation from normal occlusion in the validation study of the par index by 74 dentists . to reduce the effect of interexaminer variability the mean score of three examiners was used for the final score in the statistical comparison of results .
thus , the present study showed that the implementation of ptce improved the quality of orthodontic treatment among orthodontic residents , and the ptce should be implemented as compulsory in a postgraduate orthodontic clinic .
the quality of orthodontic care was improved significantly following the implementation of ptce in a postgraduate orthodontic clinic .
 objective : the aim of the study was to evaluate the effect of post- treatment critical evaluation on the quality of orthodontic care in a postgraduate orthodontic clinic.materials and methods : orthodontic treatment outcome of 109 consecutively treated cases was evaluated in phase - i evaluation . following phase - i evaluation , ptce of each case 
 was made mandatory . 
 after 6-years of implementation of compulsory ptce for each case , orthodontic treatment outcome of all consecutively treated cases ( n = 126 ) was evaluated ( phase - ii ) . 
 the treatment outcome was evaluated by american board of orthodontics model grading system ( abo mgs ) and subjective evaluation ( visual analogue scale , vas).results : based on the abo scores , the cases were divided into three grades , that is , grade - i , grade - ii , and grade - iii . 
 the mean total abo score was improved significantly in phase - ii evaluation ( p < 0.01 ) 
 . the total number of cases in abo grade - ii were increased significantly ( p < 0.01 ) whereas cases in abo grade - i remained comparable . 
 the vas score was improved from 5.66  0.77 at phase - i to 6.02  0.99 at phase - ii evaluation ( p < 0.01).conclusion : the implementation of ptce significantly improved the quality of orthodontic care in a postgraduate orthodontic clinic.clinical significance : grading one 's own treatment improves the quality of future treatment . 
Clinical Significance:
INTRODUCTION
MATERIALS AND METHODS
Statistical analysis
RESULTS
DISCUSSION
CONCLUSION
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Conflicts of interest