2019, Number 3
Association of malocclusion level, dental and maxillofacial alterations and satisfaction of orthodontic treatment in adolescent patients from Ciudad Juarez, Chihuahua
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ABSTRACT
Introduction: Malocclusions are one of the main alterations affecting teeth esthetics and function. Despite various evaluations for the identification and distribution of malocclusions, no study has determined the distribution and associations of level of malocclusion, dental and maxillofacial anomalies and level of satisfaction of orthodontic treatment using the Dental Aesthetic Index (DAI) in adolescent patients living in northern Mexico. Objectives: The goal of this study was to determine the association between level of malocclusion, dental and maxillofacial anomalies and level of satisfaction of orthodontic treatment and the DAI in adolescents in Juarez City, Chihuahua. Material and methods: Using a comparative cross-sectional design and consecutive non-probabilistic sampling, 150 adolescent patients between 12 and 18 years of age were interviewed and evaluated through the DAI to determine the severity and distribution of malocclusions, dental and maxillofacial anomalies and level of satisfaction of orthodontic treatment. Results: The distribution of malocclusions (normal, defined, severe and disabling) decreased frequently with the progression of severity (35.3, 29.3, 28 and 7.3%, respectively). Normal occlusion increased significantly with age in both sexes (p < 0.05). The most frequent dental and maxillofacial anomalies were teeth crowding (90%), mandibular irregularity (80%), maxillary overjet (69.3%), maxillary irregularity (68.6%), molar relationship (67.3%), and less frequent alterations such as teeth spacing (23.3%), diastema (8%), missing teeth (6%), open bite (4%), and mandibular overjet (3.3%). All anomalies were uniformly distributed among men and women (p > 0.05). The level of malocclusion showed significant associations with the level of satisfaction (p < 0.05). Conclusions: The level of dental malocclusions of adolescent boys and girls may influence the emotional satisfaction behavior related to orthodontic treatments, probably due to the presence of morphological and anatomical alterations of teeth and maxilla.INTRODUCTION
Crowded, irregular teeth with various alterations in the position of the jaws represent a serious oral problem.1 Several studies have determined that the abnormal position of the jaws, as well as the position and distribution of the teeth can have a direct impact on the development of other oral alterations causing more complex problems associated with malocclusions.1-3 Some other factors such as the current trend of consumption of soft-consistency foods with reduction of chewing forces, passive suction, digital suction, premature weaning, among others have been identified as important elements in the development of malocclusions.4,5 The prevalence of malocclusions in young people ranges from 35 to 75%, and differs according to age and ethnic group, method of registration and presence of syndromes. The most common features of malocclusion are class II molar relationship and teeth crowding; however, the main etiological factors for developing malocclusions are associated with genetic or environmental factors, a combination of both or local factors such as parafunctional habits, premature loss of teeth, loss of space associated with tooth decay, inappropriate dental restorations, among others.6 To determine a pathology, etiology is the key to diagnosis. Malocclusion is a developmental problem, not a pathology, which should be considered as a multifactor development process. For most patients the problem occurs during development, but it is impossible to accurately determine a specific cause of a patient's current condition. Considering that malocclusion is a growth problem, whatever its etiology, when the growth stage ends the etiological agents are no longer active.7 The effect of malocclusion is both functional and aesthetic, as it influences psychosocial aspects, because of the demands of today's world. The purpose of orthodontic treatment is mainly to improve a patient's quality of life; the patient seeks treatment that involves correcting malocclusion and improving function and dental and facial aesthetics, as well as oral health.8 Facial appearance and degree of attractiveness can significantly influence different aspects of an individual's personal, social and professional life. Human beings tend to adopt negative attitudes and discriminatory behavior toward those they perceive as unattractive, and, on the other hand, more positive impressions and treatment of people with attractive faces. According to some authors, smile is the second facial feature, after the eyes, that people most often tend to observe when evaluating each other's beauty.9
Some tools have emerged to evaluate the characteristics related to the position of the teeth, aesthetics, and each individual's perception. One of them is the Dental Aesthetic Index (DAI), which was designed with the objective of measuring aesthetics and associating it with psychological limitations. The DAI was accepted by the World Health Organization (WHO) in 1997 as a transcultural international index created for epidemiological purposes and has been applied to various ethnic groups without modification.10 This analysis includes the aesthetic and dental components, which when combined mathematically allow obtaining a unique score where the physical and aesthetic aspects of occlusion are combined.10 The index was designed to be used in permanent dentition in patients between 12 and 18 years of age, although it can be adapted to mixed dentition counting the number of missing incisors, canines and premolars, and in case of a newly exfoliated tooth where it appears that the permanent is about to erupt, not recording its absence. However, it is necessary to take into account the limitations of this index for its correct application, reproducibility, and reliability.11 The assessment of malocclusions through DAI is appropriate because it measures occlusal disharmony and values an unacceptable aesthetic. By establishing these two types of factors, this index makes it easier to develop future projections on the need for orthodontic treatment in a given population.6 Yet, there is no study that has used the DAI and determine the orthodontic treatment needs in persons living in the northern part of Mexico. Thus, the goal of this study was to assess the level of malocclusion, the occlusal component, and the level of self-perception of orthodontic characteristics associated with sex and different age groups in individuals currently living in Ciudad Juarez, Chihuahua.
MATERIAL AND METHODS
A descriptive cross-sectional study was conducted evaluating 150 patients between 12 and 18 years of age who sought consultation to receive dental treatment at the Dental Admission Clinic of the Department of Stomatology at the Institute of Biomedical Sciences of the Autonomous University of Ciudad Juarez in Ciudad Juarez, Chihuahua, Mexico, from February to May 2018. All patients were selected by consecutive non-probabilistic sampling. After signing an informed written consent, patients were evaluated using the DAI to determine the severity of malocclusion and their need for orthodontic treatment.10 Those included were between 12 and 18 years old and had permanent dentition completely erupted to the second permanent molar, good psychic and social status, as well as apparent absence of any significant systemic disease. Patients with prior and/or current history of orthodontic treatment, posterior cross bite and/or deep bite were excluded.
The DAI is obtained by a standard regression equation including 10 occlusal components or characteristics with their corresponding coefficients, whose rounded values are shown in Table 1. A form was made with the 10 variables that make up the DAI (missing visible teeth, anterior crowding, teeth spacing, diastema, maxillary irregularity, mandibular irregularity, maxillary overbite, mandibular overbite, open bite and molar relationship).10 Measurements of the variables were made for each individual to obtain a numerical value; then each numerical value was multiplied by its corresponding standard DAI regression coefficient and the products obtained in the previous step plus the constant with a value equal to 13 were added together. The result of this sum corresponded to the DAI value. Depending on the value obtained, the individual's occlusal state or need for orthodontic treatment was classified in Table 2. In addition, two questions outside the index were added, namely patient's self-perception of malocclusion and dental satisfaction. The data were obtained through the measurement and dental clinical examination using an oral mirror and William-Fox-type periodontal probe, and then placed in each of the sections of the pre-designed form. All clinical records were performed by a single examiner previously calibrated.
STATISTICAL ANALYSIS
The results are expressed in means, standard deviation, frequencies, and percentages. The differences between groups for qualitative variables were determined by χ2 test using the SPSS statistical package version 23. Statistical significance was considered as p < 0.05.
RESULTS
The sample consisted of 150 patients, 84 (56%) women and 66 (44%) men. The mean age was 15.3 ± 1.9 years between a range of 12 to 18 years. The highest number of individuals corresponded to the age group of 12 to 14 years for both sexes (37.3%), followed by 17 to 18 years (35.3%) and 15 to 16 years (28%).
Table 3 shows the prevalence of the type of malocclusion in the population studied and the frequency of individuals in each category determined by the index according to the severity of malocclusions and the need for orthodontic treatment. The majority of the population had a normal occlusion or minor malocclusion (53 patients; 35.3%) followed by defined malocclusion (44 patients; 29.3%), severe malocclusion (42 patients; 28%), and very severe or disabling malocclusion (11 patients; 7.3%). This means that 64.7% of patients had malocclusion with different degrees of severity and needed orthodontic treatment.
Figure 1 shows the results of malocclusion levels by age group. A predominance of the 17- and 18-year-old group with normal occlusion (16%) was observed compared with the 15- and 16-year-old group (11.3%) and the 12- to 14-year-old group (8%). Regarding the defined malocclusion and severe malocclusion levels, in both cases the 12- to 14-year-old group had a higher frequency over the other two groups. Likewise, in the disabling malocclusion level the 12- to 14-year-old group was in first position (2.3%) followed by the 17- and 18-year-old group (1.3%) and the 15- and 16-year-old group (0.6%). Significant differences were found in the normal occlusion group when comparing the 12- to 14-year-old group with the 15- and 16-year-old and 17- and 18-year-old groups, respectively. However, for disabling malocclusion the only statistical differences were found when comparing the 12- to 14-year-old group with the 15- and 16-year-old group (Figure 1A). This may indicate that the frequency of normal occlusion increases significantly with age, while disabling malocclusion will decrease with age. On the other hand, by sex, 37.8% of men showed normal occlusion, 27.3% defined and severe malocclusion (for each level), and 7.6% disabling malocclusion. As for women, 33.3% had normal occlusion, 31% defined malocclusion, 28.6% severe malocclusion, and 7.1% disabling malocclusion. Although there were variations in the frequency of malocclusion levels according to sex, no significant difference was found (p > 0.05), suggesting that the distribution according to each level of malocclusion was sex-independent (Figure 1B).
The assessment of the occlusal components included in the DAI (Figure 2A) showed that teeth crowding was the most frequent alteration, which was present in 135 individuals (90%), followed by mandibular irregularity with 120 cases (80%), maxillary overjet with 104 subjects (69.3%), maxillary irregularity (68.6%), and molar relationship (67.3%). In contrast, the less frequent DAI components were teeth spacing (23.3%), diastema (8%), missing teeth (6%), open bite (4%), and mandibular overjet (3.3%). In addition, the distribution of DAI components according to sex showed that men had a higher frequency in missing teeth, teeth crowding, mandibular irregularity and alteration in the molar relationship (Figure 2B). As regards women, they showed a higher frequency of teeth spacing, diastema, maxillary irregularity, maxillary and mandibular overjet, and open bite. The comparison of the distribution and frequency of occlusal components by sex revealed statistically similar values between men and women (p > 0.05). This suggests that the distribution of DAI components was not related to sex.
Figure 3 presents the results according to the level of satisfaction with the dental appearance. The lowest proportion of individuals claimed to be "very satisfied" (8%), showing no motivation to receive orthodontic treatment. On the other hand, the higher frequencies corresponded to the "satisfied" (38%) and "dissatisfied" (38.7%) levels, while the "very dissatisfied" level was the third lowest group (15.3%). The comparison of the satisfaction variable with dental appearance as an independent variable showed that teeth crowding causes individuals to be generally dissatisfied with their dental appearance.
Table 4 shows the results of associations of the level of malocclusion in relation to sex and the level of satisfaction. Significant associations were observed by comparing the level of malocclusion with the level of satisfaction. The "very satisfied" and "satisfied" levels found frequencies of malocclusion that gradually decreased with progress in the severity of malocclusion (20.8-0% and 47.2-31.2%, respectively), while the lower satisfaction levels ("dissatisfied" and "very dissatisfied") showed contrastingly a behavior in which frequencies increased proportionately with the advancement of the level of malocclusion (p = 0.000). On the other hand, the distribution by sex showed statistically similar behaviors at the different levels of malocclusion (p = 0.869). This indicates that the level of satisfaction was statistically related to the severity of malocclusion.
DISCUSSION
This study found that normal occlusion increases significantly with age, while disabling malocclusions are statistically less common with age in both men and women. Teeth crowding, mandibular and maxillary irregularity, maxillary overjet, maxillary irregularity and molar relationship were the most common alterations (90-67.3%) compared with teeth spacing, diastema, missing teeth, open bite and mandibular overjet (23.3-3.3%), being statistically distributed equally in men and women. On the other hand, most individuals were shown to be in a neutral area between satisfaction and dissatisfaction. These levels (38-38.7%) prevailed compared with the extreme levels of satisfaction and dissatisfaction (8-15.3%). In addition, the level of malocclusion and the level of satisfaction showed significant associations, suggesting that the level of satisfaction depends directly on the severity of the malocclusion. This could indicate that the most severe levels of malocclusion could cause lower emotional states of satisfaction in both men and women related to major dental and bone alterations. The results obtained will help to understand the satisfaction level of adolescent patients in relation to their dental and maxillofacial conditions, so that their expectations and needs lead to more appropriate orthodontic treatments.
In the study of Perez Aguilar et al., in the city of Puebla, Mexico, the distribution of malocclusions was evaluated, finding that the highest frequency occurred in the group of normal occlusion or mild malocclusion with 53.12%, while the lowest frequency group was that of disabling malocclusion with 10.11% of the sample.12 The comparison of the occlusal components in this study revealed, like ours, that teeth crowding and maxillary overjet are within the first 3 occlusal components where there is some alteration. Also, diastema and mandibular overjet were 2 of the 3 least common components in both studies. The predominance of teeth crowding as a deficient occlusal characteristic can be explained by Herpin's postulates, set forth in his theory of the phylogenetic evolution of the human chewing apparatus. According to Herpin, the decrease in the parts of the chewing system has affected mainly the muscles and bones, and to a lesser extent the teeth, which have reduced their size, but not the number. On the other hand, our findings differ from those by Gutiérrez Rojo et al., who conducted a study in the city of Guadalajara, Mexico.13 They reported very severe malocclusion in 53% of cases, severe malocclusion and definitive malocclusion in 17%, and normal occlusion in only 11.4%. When comparing results by sex, the percentages for men and women are different. The components that had the highest means were mandibular overjet, mandibular irregularity and maxillary irregularity. These results are far from those obtained in our study. However, it should be considered that the study was conducted in patients seeking orthodontic care, so the degree of malocclusion and DAI mean were basically the main reason for consultation of these patients. The study of Vizcaino et al., conducted in Tepic, Mexico,10 differs from ours in terms of malocclusion level groups. The group of normal occlusion or minor malocclusion accounted for 15% of cases and disabling malocclusion for 35% of cases. The defined and severe malocclusion groups showed similar percentages with 26 and 24% of cases, respectively. By sex, results were alike. Several studies in Cuba showed resembling results. Toledo et al.14 showed percentages similar to those of our study with 52.8% for women and 46.9% for men. The prevalence of malocclusions has similar behavior with normal occlusion or minimal malocclusion with the higher prevalence; however, in this study severe occlusion is ranked last. Like our study, 2 of the most common occlusal components were teeth crowding (69.3%) and maxillary overjet (46.6%), and the 3 least common were the same, namely missing teeth (1.1%), mandibular overjet (4.5%), and open bite (4.5%). The study by Navarro et al.15 found 69.1% of cases with teeth crowding, followed by 45.6% with maxillary irregularity and 38.23% with mandibular irregularity. Regarding the need for orthodontic treatment, 53.7% of schoolchildren did not require it or only needed some minor correction, and 5.1% required orthodontic treatment immediately. As for the position of their teeth, 77.2% of schoolchildren were satisfied and 35.3% wanted their dental occlusion to be corrected. In our study, 46% of patients were satisfied with their dental appearance, while 54% had some level of discontent about it. Our results point to a high correlation between malocclusion and its perception in adolescents. However, the differences between this study and others can be attributed to the different cultural perceptions, socioeconomic level, demographic area, and age group of the evaluated patients. The study by Mai et al.16 showed a behavior of the groups similar to that of our study presenting a higher percentage in mild malocclusion with 82.5% to follow the same order of prevalence, the lower being the disabling malocclusion with 4.6%. The study was only conducted in adolescents from 15 to 17 years of age; considering only the groups of 15 to 18 years of our study, similar results are found between both studies. The occlusal components show correlation in terms of order of prevalence, the most frequent being teeth crowding and mandibular irregularity. Alterations in the mandibular dental position may be caused by disproportion between tooth size and bone bases. In addition, given that the first permanent molars erupt first in the mandible than in the maxilla and if there is late mesial displacement, there is a greater tendency for rotations to appear. However, the results differ in the study by Fernandez Perez et al.,11 presenting a difference by sex as well as by most prevalent type of malocclusion. Our study showed a higher prevalence of mild malocclusion of 37%, while their study found a prevalence of very severe malocclusion of 29.6%. Also, men had a similar proportion of mandibular irregularity as in our study, while maxillary overjet was more prevalent in women too, with 58.5%. Consumption of increasingly soft foods may have influenced a lower development of the jaw bones, which would explain the increased incidence of orthodontic disorders. Hence the importance of advising pregnant women and mothers on the correct feeding of children. Pino et al.17 pointed to a predominance of adolescents with very severe malocclusion (28.8%), followed by those with defined malocclusion (19.8%) and severe malocclusion (9.6%). According to sex, defined malocclusion was slightly more frequent in men, while severe malocclusion and very severe malocclusion were more frequent in women, the latter result being similar as in our study. Severe malocclusion was observed in 33.4% of the total students examined by Hernandez et al.,18 following in order defined malocclusion (30%), very severe malocclusion (20.9%), and normal occlusion or minor malocclusion (15.6%). According to sex, desirable treatment (15.6%) was indicated for men and elective treatment (20.4%) for women, compared with 37% men and 33.3% women not needing treatment in this study. As for the DAI components, teeth crowding was the most representative with 61.7%, followed by some alteration in the molar relationship with 59.1%, and maxillary overjet with 45.9%. In a study conducted in Colombia by Mafla et al.,6 a similar percentage (32%) was observed for the presence of minimal malocclusion, as well as for the presence of very severe or disabling malocclusion. Severe malocclusion was present in 20.4% and defined malocclusion in 15.2% of the population studied. According to sex, the greatest severity was found in men, 37% of whom had severe malocclusion, while 27.7% of women had the same diagnosis. The same situation was observed in this study but with much lower percentages. In our study, the greatest severity occurred in men with minimal malocclusion (37.8%). The results of the study by Cartes et al.19 including Chilean students, like those of Mafla et al.,6 showed a 32% DAI degree less than or equal to 25, but do not coincide in the order of the other groups of this or of our study. These results are consistent with those of our study, where 38.5% of men did not have or had a mild level of malocclusions, this being the most representative group by sex. In addition, in general terms we can observe a higher prevalence and severity of malocclusions in women in both studies. Regarding the self-image questionnaire, 69.2% and 81.2% of men and women, respectively, felt that they had some form of malocclusion; more than 53.8% of men and 72% of women were bothered by this situation. The values shown in this study support Graber et al. claims,7 in that facial aesthetics influence women's self-esteem more than that of men. However, this is not a determinant for the need for treatment to be more sex significant. In Turkey, the value expressed by Hamamci et al.20 was 66.5% for minor malocclusion, being the most frequent group as in our study, but with a big difference in percentage. The second place was for defined malocclusion with 12% and the third for very severe malocclusion with 11.9%. The results in this study showed that 46% of adolescents noticed little or no irregularity in their occlusion, while 54% thought that they had a greater malocclusion. These results are similar as those in the population of young adults between the ages of 17 and 26 years in the study by Hamamci et al., where 48.4% reported being aware of having some degree of malocclusion. Despite that 71.1% reported being satisfied with their dental appearance and only 28.9% were dissatisfied with it.
Given that malocclusion is considered a public health problem affecting a large number of individuals in the population, we believe that the results obtained in this study offer a recent epidemiological overview on the levels of malocclusion, dental and bone alterations, and the level of satisfaction of adolescents living in the northern region of Mexico. Our results will allow improving prevention, diagnostic measures, and additional resources in orthodontic treatment as well as improvement in prognosis before, during and after conventional orthodontic procedures. Because the data obtained was only of patients attending the Dental Admission Clinic of the Institute of Biomedical Sciences in search of oral care, it is desirable to analyze a wider sample of the population and of different groups and strata to obtain a more representative sample of the degree of malocclusion and the need for treatment in Ciudad Juarez. Undoubtedly, other similar studies should be developed in the Mexican population to establish the frequency and distribution of malocclusions in the different regions of the country.
CONCLUSIONS
This study found that normal occlusion, in both men and women, increases significantly with age, while the frequency of disabling malocclusion gradually decreases. The most common dental and maxillofacial alterations that make up the DAI were teeth crowding, maxillary and mandibular irregularity, maxillary overjet, maxillary irregularity and molar relationship, while the less frequent were teeth spacing, diastema, missing teeth, open bite, and mandibular overjet, evenly distributed among men and women. In addition, the level of malocclusion and level of satisfaction showed significant associations, suggesting that the level of severity of malocclusion could play an important role in the level of satisfaction of adolescent individuals. To our understanding, this is the first study to evaluate the distribution of malocclusions and its relation to the distribution of dental and maxillofacial alterations and the level of satisfaction of orthodontic treatment in adolescents from Ciudad Juárez, Chihuahua, Mexico. It is thus recommended that the dental professional use this index in other areas of the country to perform early prevention and interception actions to deal with malocclusions in permanent dentition.
ACKNOWLEDGEMENTS
The authors thank the Dental Admission Clinic of the Department of Stomatology of the Institute of Biomedical Sciences of the Autonomous University of Ciudad Juárez for the administrative, clinical, and technical support for the development of the study.
REFERENCES
AFFILIATIONS
1 Alumno del programa de Cirujano Dentista. Instituto de Ciencias Biomédicas, Universidad Autónoma de Ciudad Juárez.
2 Profesor investigador, Especialidad en Ortodoncia. Instituto de Ciencias Biomédicas, Universidad Autónoma de Ciudad Juárez.
3 Profesor investigador, Maestría en Ciencias Odontológicas. Instituto de Ciencias Biomédicas, Universidad Autónoma de Ciudad Juárez.
4 Profesor investigador, Especialidad de Endodoncia. Instituto de Ciencias Biomédicas, Universidad Autónoma de Ciudad Juárez.
CORRESPONDENCE
Dr. Fabián de León-Chacón. E-mail: fabian.deleon@uacj.mxReceived: Octubre 2019. Accepted: Enero 2020.