ORTHODONTIC TREATMENT NEEDS IN MIXED …€¦ · The need for orthodontic treatment was high or very high for 10.13% of ... planning and interception of potential dentomaxillary malocclusions.

Romanian Journal of Oral Rehabilitation

Vol. 8, No. 1, January - March 2016

28

ORTHODONTIC TREATMENT NEEDS IN MIXED DENTITION -

FOR CHILDREN OF 6 AND 9 YEARS OLD

Anne-Marie Rauten1, Catrinel Georgescu

1, M.R. Popescu

2, Camelia Fiera Maglaviceanu

3, Dora

Popescu4, Dorin Gheorghe

4, A. Camen

5, Cristina Munteanu

5, Madalina Olteanu

3

1Department of Orthodontics, Faculty of Dental Medicine, UMF Craiova

2Department of Prosthetics, Faculty of Dental Medicine, UMF Craiova

3Department of Pedodontics, Faculty of Dental Medicine, UMF Craiova

4Department of Periodontology, Faculty of Dental Medicine, UMF Craiova

5Department of Oral and Maxillofacial Surgery, UMF Craiova

Correspondent author:

ABSTRACT:

Early identification of a developing malocclusion and initiation of simple orthodontic therapy procedure represent

ways to prevent or reduce the number of late orthodontic treatments, which can be complex, lengthy and costly. We

aimed to assess the need for interceptive therapy of dentomaxillary anomalies on a group of 147 children, 69 of age 6

years old and 78 of age 9 years old, which called for an orthodontic or pedodontic treatment during 2014- 2015 in 4

private offices in Craiova. We observed a high prevalence of caries in temporary and young permanent dentition

(52.98% for age 6 years old and 37.17% for age 9 years old) and of early loss of temporary teeth (17.39% for age 6

years old and 23.07% for age 9 years old). The need for orthodontic treatment was high or very high for 10.13% of

the children age 6 years old and 24.35% of the children age 9 years old, and small or moderate for 13.03% of

children age 6 years old and 33.33% of the children age 9 years old. IOTN can be a valuable tool in identifying,

planning and interception of potential dentomaxillary malocclusions.

Keywords: early loss of temporary teeth; malocclusions; prevention and interception in orthodontics.

INTRODUCTION:

Need to establish an orthodontic treatment in

children is increased, varying according to the

literature between a quarter and a third of this

population group members [1,2,3,4].

In many cases the development of

dentomaxillary anomalies can be early

detected, since temporary or mixed dentition

[5,6], but many doctors assess subjects in

orthodontic terms only after completion of

dental permutation. Thus they refuse an

interceptive treatment to such patients, which

performed correctly can reduce on the one hand

the risk of developing major dental mismatch,

severe malocclusions or some facial

asymmetries (the potential of skeletal growth

modification is higher at younger ages); on the

other hand it reduces the need for complex or

lengthy orthodontic treatments, providing a

more stable therapeutic results [7,8,9]. The

interception of malocclusions promotes a better

oral health care and decreases the risk of dental

caries [10,11].

There were described several indices able to

identify people who need orthodontic treatment

and to minimize the subjectivity related to the

diagnosis [12]. Shaw and co-workers (1995)

[13] divided occlusal indices into five different

categories: indices for diagnosis,

epidemiological, orthodontic treatment need,

treatment outcome, and orthodontic treatment

complexity indices. Most of them relate to

permanent dentition. The best known and used

is Index of Orthodontic Treatment Need



29

(IOTN), because it is easily reproducible and

the recording of all the relevant features of

malocclusion can be done in a minute amount

of time [14]. This index has been recommended

and widely used for patients in the full

permanent dentition but not in the mixed

dentition stage [3]. So the IOTN has two

separate components, a clinical component

called the Dental Health Component (DHC)

and an Aesthetic Component (AC). The Dental

Health Component of IOTN is divided into five

grades, with Grade 1 indicating no treatment is

required and Grade 5 showing great need for

treatment (Brook and Shaw, 1989) [15]. The

occlusal trait with the highest score indicates

the grade in which the malocclusion belongs to

determining the degree of treatment needs.

Regarding the aesthetic component it relies on

a series of 10 photographs of different

malocclusion arranged according to their

attractiveness (from the least to the most

attractive). In the original study the scale for

AE assessment was determined by Evans &

Shaw (1987) [16] for a lot of children of age 12

years old. In 2014 Mohamed et al. [1] tried to

assess whether IOTN may find utility in

interception, by assessing occlusal changes in

the frontal maxillary and mandible in a group

of children aged 8-10 years old, concluding that

IOTN is effective in identifying dentomaxillary

anomalies linked to increased overjet and

overbite or to the presence of crossbite.

Specific index for mixed dentition that allows

early detection of developing malocclusion is

the index for preventive and interceptive

orthodontic need, IPION, described by Coetzee

(1997) [17]. IPION consists in recording of

various occlusal traits that have scores

depending on their severity. The trait scores are

then added, yielding a total score that indicates

the need for preventive or interceptive

orthodontic treatment [3]. The index does not

show the real prevalence of malocclusion,

however, because there are severe

malocclusions that can not benefit from

preventive or interceptive treatment, which

according to this index, have a low score [3].

It may be possible because of the small number

of studies that have dealt preventive and

interceptive orthodontics over the years and of

the growing interest in this subject in recent

years (Karaiskos et al., 2005 [3]; Silkestrand,

2007 [2] Sandoval and colab.2010 [18]; Borre

2013 [19]; Mohamed et al. 2014 [1]).

The purpose of the present study was to

investigate by means of some occlusal

parameters analysis how necessary is a

preventive or interceptive orthodontic treatment

in several dental officies with private practice

in Craiova, for children aged 6 and 9 years old.

The two age groups were chosen because at 6

years of age starts the mixed dentition phase,

and within this phase the age of 9 years old

marks the beginning of canin-premolar group

eruption, when it completes the arch and

harmonious implanting of permanent teeth into

the alveolar arch and anterior and lateral

guidance in eccentric motion of the mandible

[20].

MATERIAL AND METHOD

The study was conducted during 2014-2015 in

four private dental offices in Craiova with

orthodontics and pedodontic activity. Were

targeted children aged 6 and close to 9 years

old, resulting in a sample of 147 children for

which informed consent was obtained from

caregivers in order to use clinical data records

and analysis of study models and dental

radiographs.

In order to determine the necessity of

establishing a preventive or interceptive

orthodontic treatment depending on the age



30

they were valued for each child from the study

group more clinical parameters which are

shown in Table 1.by two different examiners.

6 year olds 9 year olds

Caries

Early loss

Molar relationship

Overjet

Overbite

Anterior crossbite

Posterior crossbite

Open bite

Caries

Early loss

Molar relationship

Overjet

Overbite

Anterior crossbite

Posterior crossbite

Open bite

Submerged teeth

Active frenum

Table 1. Analyzed clinical parameters

Molar relationship appreciation was based on

Angle occlusal classification of malocclusions

[21].

The overjet was assessed in millimetres as the

distance between the edge of the upper central

incisor and the labial surface of the lower

central incisor measured in millimeters. Overjet

between 0.1 and 3 mm was considered as

normal, greater than 3 mm was considered as

increased, and 0 mm was taken as edge to edge.

The open bite was measured in millimeters as

the perpendicular distance from the edge of the

central lower to the upper central incisor edge.

The calculated IOTN scores of the 6 and 9 year

old children were mainly based on labial

segment of the upper and lower arches. The

occlusal traits that were scored upon were the

overjet, anterior crossbite, posterior crossbite,

overbite and open bite.

For conformity assessment between clinical

examinations results, the intra-examiner

agreement was set at 10%.

The collected data were statistically analyzed

with the dedicated software (SPSS 16.0,

Chicago, IL, USA). Differences between

groups were calculated using the Mann

Whitney UU test and for correlations among

the groups the Pearson test was used. All

results were tested for statistically significant

differences between age groups and genders

using the χ2 test [22]. Inter- and intra-examiner

agreement was evaluated using the weighted

kappa statistic.

RESULTS

69 patients of the subjects included in the study

were aged around 6 years old (6 years ± 3

months) and about 78 around 9 years old (9



31

years ± 6 months). Within the 6 years old

group, 39 (56.52%) were girls and 30 boys

(43.48%) and from those of age 9 years old, 41

(52.56%) were girls and 37 boys (47.44 %).

Caries: In the 6-year-old group, 24% of

children had caries affecting 1 tooth and

28.98% had caries affecting more than 1 tooth;

in the 9 years old group, 16.66% had caries

affecting 1 tooth and 20.51% had caries

affecting more than 1 tooth (table 2).

The most affected tooth by carries was primary

second molar: for 6 years old in 39.47%, and

for 9 years old 37.70% (table 3).

Early loss of temporary teeth: 12 of the 6

years old subjects (17.39%) and 18 of the 9

years old (23.07%) had early loss for ≥ 1 tooth.

The most commonly missing teeth were the

primary first molars (43,75%), followed by the

primary canines (31.25%) for the 6 years old;

in the 9 years old, the primary canines

(46.15%) were most commonly missing,

followed by the primary first molars (19.23%)

(table 4).

No. of

teeth

No. (and %)

of 6 years

old

No. (and %)

of 9 years old

0

1

≥1

32 (47.02%)

17 (24%)

20 (28.98%)

49 (62.82%)

13 (16.66%)

16 (20.51%)

Table 2. Number of teeth affected by caries

Tooth affected

No. (and %)

of 6 years

old

No. (and %)

of 9 years

old

Primary incisors

Primary canines

Primary first molars

Primary second

molars

Permanent first

6 (7.89%)

5 (6.57%)

23 (30.26%)

30 (39.47%)

12 (15.78%)

0 (0%)

7 (11.47%)

18 (29.50%)

23 (37.70%)

13 (21.31%)



32

molars

Table 3. Teeth most commonly affected by caries

Tooth affected

No. (and %)

of 6 years

old

No. (and %)

of 9 years old

Primary canine

Primary first molar

Primary second

molar

5 (31.25%)

7 (43.75%)

4 (15.00%)

12 (46.15%)

9 (34.61%)

5 (19.23%)

Table 4. Teeth most commonly affected by early loss

Molar relationship: For 6 years old group

22 subjects (31.88%) could not be included in a

class of malocclusion by Angle because that

they had no erupted first permanent molars, and

for 9 years old group 2 patients (2.56%) to

which early extraction of first permanent

molars did not allow the assessment of this

relationship.

Of the 47 children of 6 years old group with

molar relations, 62.3% had a class I

malocclusion, 32.1% class II and 5.7% class III

by Angle, and of the 76 subjects of 9 years old

group 53.84% showed class I malocclusion,

35.89% class II and 7.69% class III after Angle

(table 5).

Classification

No. (and %)

of 6 years

old

No. (and %)

of 9 years

old

Not

measurable

Class I

Class II

Class III

22 (31.88%)

31 (44.92%)

12 (17.39%)

4 (5.79%)

2 (2.56%)

42 (53.84%)

28 (35.89%)

6 (7.69%)

Table 5. Molar relationships by Angle classification



33

Overjet: 7 of 6 years old subjects (10.14%) showed an increased overjet, while for the group of 9

years old the number was much higher, 43 subjects (55.12%) (Figure 1).

Figure 1. Number of children with overjet

Overbite: 5 subjects of 6 years old and 37 subjects of 9 years old (47.43%) presented an increased

overbite (7.24%) (Figure 2)

.

Figure 2. Number of children with overbite

Openbite: 12 of subjects of 6 years old (17.39%) and 9 of the subjects of 9 years old (11.53%)

were diagnosed with open bite (Figure 3).

Figure 3. Number of children with open bite



34

Crossbites: There were found to be more

common in the anterior segment than the

posterior segment for both groups. In the 6

years old group 5.79% (4 subjects) exhibited

anterior crossbite. In the 9 years old group

14.10% (11 subjects) exhibited more than 1

tooth in crossbite.

Posterior crossbites occurred in 4.34% (3

subjects) of the 6 years old children, while in

the 9 years old children the percentage was

8.97% (7 subjects).

Submerged teeth and active fraenum: For

the 9 years old group the percentage of subjects

with submerged teeth and active fraenum was

very small 2.56% (by 2 subjects for each

anomaly).

The IOTN score were mainly based on

occlusal alterations in the labial segment of the

upper and lower arches. 10.13% of the children

from the 6 years old group and 24.35% of the

children from the 9 years old group have a high

or very high need of orthodontic treatment

(table 6).

IOTN scores No. (and %)

of 6 years old

No. (and %)

of 9 years old

1 No need for treatment 53 (76.81%) 33 (42.30%)

2 Little need for treatment

3 (4.34%) 5 (6.41%)

3 Moderate need for treatment 6 (8.69%) 21 (26.92%)

4 Great need for treatment 5 (7.24%) 14 (17.94%)

5 Very great need for

treatment

2 (2.89%) 5 (6.41%)

Total

69 (100%) 78 (100%)

Table 6. Distribution of IOTN in relation to labial segment malocclusion

DISCUSSIONS:

Interceptive orthodontic treatment is generally

defined as treatment aimed to eliminate or

reduce unfavourable ongoing signs of

malocclusion, thus providing favourable

conditions for normal growth [2]. There are

conflicting views over the need for early

orthodontic intervention. Those who are against

treatment in mixed dentition argue the

existence of clinical situations where the

interceptive treatment does not eliminate the

need for curative treatment [23] and the

shortening of the treatment duration for 2-3



35

years if its onset is delayed after the eruption of

premolars and permanent second molars [5,24].

They sustain that by delaying is can be lost the

moment when the skeletal growth can be

influenced, the dental alveolar can be guided

and bad habits deconditioning is the least

difficult [10,11,24,25]. The need for a complex

fixed orthodontic treatment is significantly

reduced [23,26] and may have an adverse effect

on dental health and surrounding tissues [24].

According to the American Academy of

Paediatric Dentistry (AAPD) [27], factors we

should keep in mind when choosing the

initiating of and orthodontic treatment in mixed

dentition period are: chronological/

mental/emotional age of the patient and the

patient’s ability to understand and cooperate in

the treatment; intensity, frequency, and

duration of an oral habit, parental support for

the treatment, compliance with clinician’s

instructions, craniofacial configuration,

craniofacial growth, concomitant systemic

disease or condition, accuracy of diagnosis

appropriateness of treatment, timing of

treatment.

Among the clinical parameters that we

considered necessary to investigate for

determining which would be the need for

preventive or interceptive methods of

dentomaxillary anomalies, caries were a

common symptom. 52.98% of patients in 6

years old group and 37.17% in 9 years old

group had at least one tooth affected by decay.

This percentage is below the World Health

Organization report, according to which 60-

90% of the school population is affected by

caries [28], but the result should rather be

considered with caution given the low

addressability to private dental offices for

treatment of dental injuries on deciduous teeth.

It must not be forgotten that caries are among

the etiological factors of early loss of deciduous

teeth [29]. In our study population-based

sample 17.39% of subjects in 6 years old group

and 23.07% in 9 years old group showed early

loss of more than 1 tooth, these percentages

being consistent with data reported in the

Romanian literature [30]. In turn early loss of

temporary teeth can have varying effects such

as shortness of dental arch [10] up to 4 mm

[31]; early loss of temporary canines can lead

to the collapse of the mandibular anterior

region with subsequent collapse of the

maxillary anterior region [31] and the

emergence of incongruency of permanent front

teeth [10,32], to ectopic eruption [33], staying

in impaction of permanent canine or

interincisive line diversion [32]; early loss of

second temporary molar can result into

migration in the sagittal plane of the first

permanent molar and a molar relationship of

class II or III [34].

In this study the majority of the children were

found to be Class I after Angle, 62.3% of

children in 6 years old group and 53.84% in 9

years old group, like other previous Romanian

studies that found class I malocclusions as the

most common [35-36].

Although the proportion of subjects with

malocclusion class II and III, ranked second

and third as the frequency, is much lower, this

subjects are candidates for interceptive

orthodontic treatment if only to prevent dental

class III to become skeletal [37], or to reduce

the risk of injuries to the upper incisors in

patients with malocclusion class II [38].

The other analyzed occlusal parameters

(previously presented), the overjet, overbite,

open bite, depending on the severity and the

simple presence of the cross bite, may represent

themselves the reason for initiating orthodontic

treatment in mixed dentition. Thus at this stage

of development of teeth the overbite and

overjet may increase with the eruption of



36

permanent incisors [39], but if overcoat degree

is bigger than 5 mm, we might suspect an

evolution towards covered deep bite [5].

Detrimental effects of a deep bite include TMJ

problems [40], attrition of the anterior teeth,

direct trauma of the palatal gingiva and

periodontal problems [41]. A deep bite could

also restrict the development of the mandibular

anterior dentoalveolar process, which is

difficult to subsequently treat [24]. Open bite

may be accompanied by multiple functional

disorders: atypical swallowing of protrusion

type [42], oral breathing, chewing [43] and

phonetic [44] disorders.

Anterior cross bite untreated cause attrition to

the labial surface of the upper incisor, fractures

or mobility of incisor teeth, gingival recession

or temporomandibular joint dysfunction [45-

46]. Untreated lateral cross bite is one of the

etiological factors of a narrow jaw [47], a facial

asymmetry [48], or TMJ dysfunction through

asymmetric condylar growth or as a result of

the side slide of the mandible [49-50].

IOTN scores mainly based on occlusal changes

in labial segment of the upper and lower arches

that we analyzed was 10.13% for children in 6-

year old group and 24.35%for children in 9-

year old group. The IOTN value for 9-year old

group is very similar to that found by Karaiskos

et al. (2005) [3] of 28% for the same age group

based on calculation of IPION and smaller than

the percentage of 33% identified by Kerosuo et

al. (2008) [51] or Al Nimri and Richardson

(2000) [52] based on IOTN determination.

CONCLUSIONS

1. It is possible to identify early development of

progressive malocclusion symptoms since the

onset of mixed dentition.

2. They can be highlighted by IOTN and are in

agreement with the acronym 'MOCDO' -

missing, overjet, cross bite, displacement and

overbite.

3. Early treatment of these changes can create a

normal occlusal relationship and a balanced

neuromuscular environment at an early age

which helps the normal growth of the facial

skeleton.

4. IOTN can be a valuable tool in identifying,

planning and interception of potential

malocclusions.



37

Acknowledgment

This paper was published under the frame of the research contract no 835 from 17.07.2014.

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ORTHODONTIC TREATMENT NEEDS IN MIXED …€¦ · The need for orthodontic treatment was high or very high for 10.13% of ... planning and interception of potential dentomaxillary malocclusions.

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