ORIGINAL ARTICLE PATTERN, PREVALENCE AND SEVERITY OF MALOCCLUSION AMONG UNIVERSITY STUDENTS Rozina Nazir 1 Nasreen Amanat 2 Kulsoom Fatima Rizvi 3 BDS, FCPS BDS, MSc, FDSRCS BDS, MSc, DDPHRCS INTRODUCTION alocclusion is defined as an occlusion in which there is an abnormal relationship, or there are irregularities in tooth position beyond normal limits. 1 Malocclusion has a great impact on both person and society in terms of quality of life, anxiety, and social and functional confines. 2 A person with malocclusion may feel introverted in social circumstances, might develop a feeling of disgrace about their dental appearance and or lose career opportunities. 3 The decision to start orthodontic treatment is influenced by self-perception of dental appearance, confidence, the wish to look attractive, gender, age, and contemporary norms. 4,5 The main advantage of orthodontic treatment is enhancement of physical function, improvement of esthetic components and avoidance of tissue damage. 6 Numerous features can describe the position and occlusion of teeth, but it has always been difficult to make reliable assessments of dentofacial characteristics, the main difficulties being the definition of criteria and standardization of examiners. 7 Methods of recording and measuring malocclusion can be broadly divided into two types i.e. qualitative and quantitative. 8 While the severity or the extent to which a malocclusion deviates from the normal or ideal occlusion can be quantified by using number of varaibles, 9 among the qualitative methods of recording malocclusion, Angle’s method of classifying malocclusion with or without modifications is probably the most widely used method. Angle's classification of malocclusion in 1899 was a significant step in the progression of orthodontics. 10 It not only subdivided the main types of malocclusion, but also presented the first patent definition of normal occlusion. Ever since, several indices and classifications have been developed but as so far none has been unanimously 1 Assistant Professor & HOD Orthodontic Bahria University Medical and Dental College 2 Principal (Dental Section) Professor & HOD Oral Maxillofacial Surgery Bahria University Medical and Dental College 3 Assistant Professor & HOD Community Dentistry Bahria University Medical and Dental College Correspondence: Dr Rozina Nazir <[email protected]> JPDA Vol. 22 No. 01 Jan-Mar 2013 13 OBJECTIVE: To determine the pattern, prevalence & severity of malocclusion among university students. METHODOLOGY: A cross-sectional study was conducted among 521 University students, age ranged from 17- 24 years while mean age was 19.7 years (SD±1.8). Students were examined for malocclusion using Angle's Classification and overjet, overbite, crossbite,anterior crowding, smile arc, generalized spacing & midline diastema. Statistical analysis was carried out using chi-square test. Descriptive statistics and Cross tabulations of Malocclusion Traits i.e. Crowding, spacing, overjet, overbite, crossbite, Smile arc and gender differences, with Angle’s Classes were also performed. RESULTS: Angle’s Class I Malocclusion was most prevalent (41%). Anterior Crowding in 42% students was a major occlusal finding. Increased overjet was found in 30% of the population. No obvious gender difference was noted, except for increased overbite (more prevalent in boys, P<.001). CONCLUSION: Majority of the university students had malocclusion. Class 1 malocclusion and anterior crowding were the most common finding. KEYWORDS: Pattern, Prevalence, Severity, Malocclusion, Angle’s Classification How to cite this article: Nazir R, Amanat N, Rizvi KF. Pattern, Prevalance and Severity of Malocclusion Among University Students. J Pak Dent Assoc 2013;22(1):13-18. M
Transcript
ORIGINAL ARTICLE
PATTERN, PREVALENCE AND SEVERITY OF MALOCCLUSIONAMONG UNIVERSITY STUDENTS
Rozina Nazir1
Nasreen Amanat2
Kulsoom Fatima Rizvi3
BDS, FCPSBDS, MSc, FDSRCSBDS, MSc, DDPHRCS
INTRODUCTION
alocclusion is defined as an occlusion in whichthere is an abnormal relationship, or there are
irregularities in tooth position beyond normal limits.1
Malocclusion has a great impact on both person and societyin terms of quality of life, anxiety, and social and functionalconfines.2 A person with malocclusion may feel introvertedin social circumstances, might develop a feeling of disgraceabout their dental appearance and or lose careeropportunities.3
The decision to start orthodontic treatment is influencedby self-perception of dental appearance, confidence, the
wish to look attractive, gender, age, and contemporarynorms.4,5 The main advantage of orthodontic treatment isenhancement of physical function, improvement of estheticcomponents and avoidance of tissue damage.6 Numerousfeatures can describe the position and occlusion of teeth,but it has always been difficult to make reliable assessmentsof dentofacial characteristics, the main difficulties beingthe definition of criteria and standardization of examiners.7
Methods of recording and measuring malocclusion canbe broadly divided into two types i.e. qualitative andquantitative.8 While the severity or the extent to which amalocclusion deviates from the normal or ideal occlusioncan be quantified by using number of varaibles,9 amongthe qualitative methods of recording malocclusion, Angle’smethod of classifying malocclusion with or withoutmodifications is probably the most widely used method.Angle's classification of malocclusion in 1899 was asignificant step in the progression of orthodontics.10 It notonly subdivided the main types of malocclusion, but alsopresented the first patent definition of normal occlusion.Ever since, several indices and classifications have beendeveloped but as so far none has been unanimously
1 Assistant Professor & HOD OrthodonticBahria University Medical and Dental College
2 Principal (Dental Section)Professor & HOD Oral Maxillofacial SurgeryBahria University Medical and Dental College
3 Assistant Professor & HOD Community DentistryBahria University Medical and Dental College
OBJECTIVE: To determine the pattern, prevalence & severity of malocclusion among university students.METHODOLOGY: A cross-sectional study was conducted among 521 University students, age ranged from 17-24 years while mean age was 19.7 years (SD±1.8). Students were examined for malocclusion using Angle'sClassification and overjet, overbite, crossbite,anterior crowding, smile arc, generalized spacing & midline diastema.Statistical analysis was carried out using chi-square test. Descriptive statistics and Cross tabulations of MalocclusionTraits i.e. Crowding, spacing, overjet, overbite, crossbite, Smile arc and gender differences, with Angle’s Classeswere also performed.RESULTS: Angle’s Class I Malocclusion was most prevalent (41%). Anterior Crowding in 42% students was amajor occlusal finding. Increased overjet was found in 30% of the population. No obvious gender difference wasnoted, except for increased overbite (more prevalent in boys, P<.001).CONCLUSION: Majority of the university students had malocclusion. Class 1 malocclusion and anterior crowdingwere the most common finding.KEYWORDS: Pattern, Prevalence, Severity, Malocclusion, Angle’s ClassificationHow to cite this article:Nazir R, Amanat N, Rizvi KF. Pattern, Prevalance and Severity of Malocclusion Among University Students. JPak Dent Assoc 2013;22(1):13-18.
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accepted. This could be due to differences in theterminology, sampling differences of gender and age,height of severity and the accuracy of examining techniques.Moyers11 considered it the most useful and well knownmethod of studying occlusion, and Graber and Vanarsdall12
also confirmed the practicality and ease of this system.Quantitative means of calculating and recording occlusalcharacteristics are essential for epidemiologists and forthose forecasting the condition of orthodontic services ina certain community. Genetic, environmental or acombination of both factors, along with a variety of localfactors such as bad oral habits and abnormality in number,form, and developmental location of teeth, can lead tomalocclusion.13 Malocclusion increases the incidence ofdental caries, also affects periodontal health, and causestemporomandibular joint disturbances and severepsychological problems.1Therefore, it is essential todetermine the incidence of malocclusion and its happeningand distribution in a community.
In current years, there has been a steady rise in thequantity of adolescent and adult patients looking fororthodontic treatment in the dental colleges and othercommunity or private dental centers. The occurrence ofbusy dental clinic and long waiting lists is a sign of thedisparity between the increasing demand for orthodontictreatment and the deficiency of funds needed to offer highquality oral health services in Pakistan.Very few studieshave assessed the pattern, prevalence and severity ofmalocclusion in Pakistan. This study aimed to offer oro-dental health care planners with update on, the incidenceof individual characters of malocclusion, includinganteriorposterior relationship, overbite, open bite, overjet,anterior and posterior crossbite, irregularity score for upperand lower anteriors, midline diastema, smile arc and thegender distribution of occlusal difference and whether amajor difference be present among the population examined.Study of the frequency of occlusal characters in remotehuman populations can give important informationregarding the etiology of malocclusions and other complextraits. The documents will be useful to provide aquantitative information on pattern of malocclusion amongPakistani population which is important for planningcommunity orthodontic and dental services, and to aidfurther studies on etiology, environmental and geneticinteractions and their effect on malocclusion.
MATERIALS & METHODS
This cross sectional study was conducted at Bahria
University in october 2011. The sample consisted of 521students from Bahria University (263 boys and 258 girls) belonging to different areas of Pakistan. The studentswere provided with information on the study protocol andinformed concent was taken. The criteria for selection was:No previous history of orthodontic treatment, Age between17-24 years, no history of disease, trauma or surgicalprocedure that could influence occlusion, permanentdentition present with no retained deciduous teeth and nomultiple missing teeth. Oral examinations were performedby two trained examiners in Dental OPD. Examinationwas carried out while the patient was sitting in a dentalchair by using dental mirror, probe and a ruler.
Clinical examination of each participant was done andthe occlusal relationship was recorded in centric occlusionas described by Parker.14 Angle’s Classification was usedto describe the anteroposterior relationship of maxillaryand mandibular first molars during maximumintercuspation, it was recorded as Normal occlusion,ClassI, Class II and Class III malocclusion.10 Overjet ( 1-2mmnormal, >3mm increased,<1mm decreased, edge to edge,negative) ,overbite (0-2mm normal, >2mm deep, openbite) anterior crowding ( 1-3mm mild, 4-6mm moderate,>6mm severe), anterior cross bite, posteriorcrossbite(bilateral, right and left) midline diastema (space > 1 mm between the central incisors) and pattern of Smilearc (consonant, nonconsonat or flat and reverse) wererecorded. For Smile Arc Analysis full frontal smilephotograph of every student was taken and evaluated.The software used for data analysis was SPSS version 15.Descriptive statistics were calculated to find the meansand standard deviations. Data collected were pooled todetermine frequencies, and cross tabulations ofmalocclusion traits with Angle’s classification wereevaluated using chi-square test. Smile arc was crosstabulatedwith overbite.
RESULTS
Out of 521 Students, 263(50.5%) were boys and258(49.5%) were girls. Age range was 17 – 24 years withmean age of 19.7 years (SD±1.8). The distribution ofmalocclusion is presented in Fig 1. Angles Class Imalocclusion was most prevalent (41%). 30% of thepopulation had increase overjet, mostly present in ClassII malocclusion group. 28% had deep bite and 5.4% haveanterior open bite. Anterior crossbite was present in 3.1%individuals and was present mostly in Class IIImalocclusion. Posterior cross bite was registered in 7.3%,generalized spacing was found in 6.7%, while midline
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diastema was found in 6.9% ( shown in Table 1).Anterior Crowding found in 42% students was a majorocclusal finding and was mostly found in Class I and IImalocclusion groups as shown in Table 2.Pattern of Smile arc distribution shows that Flat Smile arcwas present in 31.7% and Reverse Smile arc in 8.8%which frequently occured in anterior open bite groups asshown in Table 3.
No obvious gender difference was noted, except for anincreased overbite which was most prevalent in boys.(P<.001).
DISCUSSION
Many studies, although, have been published describingthe frequency and types of malocclusion, it is hard toevulate, contrast and compare these findings; partially,due to different methods and indices used to evaluate theocclusal findings, specific objectives, examiner subjectivity,age variations of study populations and different samplesizes.15 The technique used in this study was taken fromdifferent studies. 16,17,18 Malocclusion was found in 79% ofour sample. This rate was almost same as reported byAfzal et al19 and higher than reported by Guray et al20 andUgur et al.21 Ugur et al21 and Proffit et al22 have reportedthat with increase in age of patients orthodontic treatmentneeds increases, age range of this study was higher ascompared to other studies.
Angle’s Class I was most frequent in our studypopulation(41%)as compared to Class II (31%) and its
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Table:3 Pattern of Smile Arc Distribution
Malocclusion in Students
250
200
150
100
50
0
40.69%
20.73%
30.90%
7.68%
Normal Occlusion Class I Malocclusion Class II Malocclusion Class III Malocclusion
Freq
uenc
y
Fig. No. 1 Frequency and Distribution of sample byAngle’s Classification
Table:2 Frequemcy of Anterior Crowding in Relationto Angle’s Classes
Table: 1 Frequemcy of Distribution of Different Traitsof Malocclusion in Relation to Angle’s Classes
almost same as reported by Afzal et al.20 On the contraryIjaz A,23 Hameed et al24 & Erum et.al.25 reported Angle'sClass II as the most common pattern of malocclusion. Thisvariation correlates with the fact that different populationgroup was chosen in our study. In this study and studiesby Shehzad et al26 and Afzal et al19, data was collected fromDental OPD as opposed to orthodontic OPD in otherstudies.27 In North American Caucasian children, Massler28
studied 2758 children and also found Class I to be mostfrequent. In a study by Silva and Kang,15Latin adolescentsconfirmed increased frequency of Class I malocclusion(69.4%). Onyeaso18described that Class I malocclusionwas more frequent in Nigerian adolescents (50%)Lauc29
described that Class II malocclusion was more frequentin their population (45.1%), and described this number bya genetic influence on the prevalence of Class IImalocclusions.The prevalence of Class III malocclusion(7.68%) determined in this study is almost same as Khanet. al.27 On the contrary, lesser rates were reported byErum25, Silva and Kang15 and Onyeaso.18 However Haynes30
(2.5%), Proffit et al22 (5.7%) and Thilander et al16(5.8%)reported even lower rates. The current study confirmedthat the predominant sagittal relationship of our populationis Angle’s Class I.
We found high percentage of increased overjet (30%)and overbite(27.8%) in this study was mostly associatedwith Class II malocclusion group.Our findings agree withthose of Erum et. al.25 in Pakistan,Thilander et al16 inBogotanian adolescents and Ciuffolo et al17 in Italianadolescents who reported higher rate of increased overjet. In a Nigerian population, Onyeaso18 reported that increasedoverjet was not as large as it was in white people.
Among vertical anomalies, deep bite was more thanfour times(28%)as frequent as anterior open bite(5.4%).Our results were comparable to the rates reported byothers16,25,29as deep bite was frequently related with a ClassII malocclusion and more frequent in boys. The studiesby Nganga et al31 and Garcia et al32 showed a higherprevalence of anterior open bite. These disparities couldbe due to difference in development and growth of thearches, or due to different harmful oral habits, tonguethrusting, mouth breathing, or dental and alveolar anomaliesof the jaws. There was no statistically significant differencesin any of the above citied studies between boys and girls.
Crowding in the anterior segment was the most commonof all anomalies recorded (41%). This finding compliedwith the results of others.16,25,29Yet, other studies havereported lesser rates of anterior crowding.18,30 NutritionSurvey III by National Health was carried out in the USA
between 1989 and 1994 explained the incidence of crowdingranging from 42.3% at ages 8–11 to 54.5% at ages 12–17which was almost equal to the frequencies observed inthis investigation.Anterior crossbite was present in 3.1% while unilateral &bilateral posterior crossbite was 7.3%. Among unilateralposterior cross bite right side was effected more. This ratewas comparable to the findings of Thilander et al16 andwas less than Ciuffolo et al.17
Thilander et al16 found the incidence of 4% mediandiastema in their population in the permanent dentition.Lauc29 observed an elevated rate of midline diastema(45.1%). The incidence of diastema in Nigeria was 24%.Onyeaso18 pointed out that diastema is not considered asa malocclusion amongst Nigerians but as a symbol ofnatural beauty.In contrast this study showed mediandiastema of 6.9% & generalized spacing of 6.7%.Consonant smile arcs are present in both genders but morein girls and flat & reverse smile arcs were more commonin boys. This study shows that flat and reverse smile arcis mostly present in cases with anterior open bite. Thisdemands that we rethink some of our orthodontic mechanicsand concepts of treatment to consistently build this factorinto our diagnostics, treatment planning, and treatmentregimens.Orthodontic history, beginning with Angle andWuerpel, has taught us that the “art of the smile” lies inthe clinician’s ability to identify the essentials of beautyin every patient to create a plan to augment thecharacteristics and identify the limitations. Advancetechnologies basically improve our ability to see patientsmore with passion and make possible the emergence ofnewer ideas of function and esthetics.
It is clear that numerous genetic and environmentalinteracting features are associated with the etiology ofmalocclusions. Specific factors like muscle dysfunction,skeletal and dental growth disturbances, disorders inembryologic and orodental development, soft diet, tonguetrusting, mouth breathing, sucking, and other habits aswell relate with heridity in the progression of major typesof malocclusion.The complexity in unraveling these factorsis obvious in terms of gene–environment interactions,intraoral ecological change is a critical factor but thischange may also disclose formerly masked genetic effects.
Well educated, trained and experienced specialists candevelop indices appropriate for the local needs, worktogether in teams, develop the educational quality andfacilities in dental schools and private clinics, and encourageepidemiological research projects. In this study numberof variables are used while evaluating patterns of
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malocclusion which mostly were not used in local studies.Due to the difference in racial and ethnic background,differences in malocclusion characteristics between Pakistanand other countries is expected.
CONCLUSION
Our findings suggest that almost 79% of young adultshave malocclusion, while Angle’s Class I malocclusion(41%) as most prevalent malocclusion trait. Anteriorcrowding (42%) was a major occlusal finding.
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