2020, Number 2
Cephalometric and sociodemographic characterization of patients who consult an orthodontics posgraduate program
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ABSTRACT
Introduction: The impact of socio-demographic variables on the prevalence and consequences of malocclusion is difficult to determine. Objective: To determine the prevalence and severity of cephalometric characteristics of patients and their relationship with oral habits and socio-demographic factors. Material and methods: This is an analytical cross-sectional observational study using calibrated evaluation (Kappa > 0.8) of 140 lateral cephalometric radiograph and medical records of patients who attended the Postgraduate in Orthodontics at the University of Antioquia (Medellín) from 2012-2015 and met the selection criteria. Parametric tests (p < 0.05) were used to relate cephalometric and sociodemographic characteristics: Pearson correlation coefficient and Student's t-test for quantitative variables (p < 0.05); odds ratio (OR) to investigate the relationship between demographics and the cephalometric features present in the malocclusion. Results: The majority were young patients (46.2%) from the lower and lower-middle strata (91.4%) and were seen mainly for aesthetic reasons (85%). Class II malocclusion was the most prevalent (45.7%), while class III was consulted for functional problems (OR = 4.09; CI 95% 1.5-11.1). A statistically significant relationship was found between the vertical classification of malocclusion (hypo, normo and hyperdivergent) with oral habits (sucking habits [p = 0.019], atypical swallowing [p = 0.045] and mouth breathing [p = 0.036]). Conclusions: Socio-demographic variables do not influence malocclusion. Oral habits were related to vertical malocclusion. The primary reason for consultation was aesthetic. Class II malocclusion was the most common and class III patients seem to be more aware of their functional problems.INTRODUCTION
Malocclusion can produce functional and/or aesthetic alterations, and influence or promote some psychosocial alterations.1,2 Several diagnostic tools can be used to assess malocclusion in patients. These include lateral cephalometric radiograph (LCR), which allows comparison of the patient's measurements, or population averages derived from multiple studies.3,4 which establish relationships of position, size and rotation of bone, dental and facial structures.5-9 However, no single study or statistic is sufficient to determine an accurate diagnosis of malocclusion. In the clinical history of a patient, it is important to include his or her demographic profile, as some of these factors appear to be associated with malocclusions, although evidence of such influence is difficult to determine.10,11
Notably, there is little information available on the cephalometric and sociodemographic characteristics of those attending the Postgraduate in Orthodontics at the University of Antioquia (Medellín).12 Given the relevance of the possible associations between malocclusion and the demographic profile, the purpose of this research was to describe the cephalometric characteristics of patients attending the Postgraduate in Orthodontics and their association with socio-demographic variables.
MATERIAL AND METHODS
An analytical cross-sectional observational study was carried out, in which standardised LCR and clinical records were evaluated from patients who attended the Postgraduate in Orthodontics at the University of Antioquia (Medellín) between 2012 and 2015. The sample was non-probabilistic and included medical records of patients who had standardised LCR. Also they had to meet the selection criteria: older than 14 years, have attended in the period 2012-2015, have initial LCR, and complete socio-demographic data in the clinical history. Patients with poor quality diagnostic cephalic radiographs, with syndromes, traumas, and/or systemic diseases or who had previous orthopaedic and/or interceptive and/or preventive orthodontic treatment were excluded. The digital radiographs were taken by a single operator, with the same equipment (Orthophos XG by Sirona®) and in the same radiology centre. Cephalometric variables (ICI-NB [o], A-perp N, Co-A, Co-Gn, Go-Pg, Ar-Go-Gn, SN, IMAX, IMPA, SBA, Y-Axis [Ricketts], PP-AB, U1-PP, SNA, SNB, Pog-N-B, ANB, Wits, Sn-Go-Gn, ICS-NA [mm], ICS-NA [o], ICI-NB [mm]) were evaluated.
Information on sociodemographic characteristics (sex, age, occupation and socioeconomic status) and variables of interest such as reason for consultation (aesthetics, health, occlusion, social pressure and referral) and oral habits (digital suction, atypical swallowing, mouth breathing, lip interposition, tongue thrusting, object biting and others) were extracted from the medical record.
A pilot test was carried out with 10 randomly selected patients, who underwent LCR; socio-demographic data were recorded in the clinical history and it was recorded whether or not the patient had oral habits. All cephalic radiographs were digitally traced using Dolphin Imaging 11.8, by blind calibration (Kappa > 0.8 ICC > 80%).
Statistical analysisSPSS version 24.0 (SPSS Inc, Chicago, IL) was used. Averages and standard deviations were used. To determine associations and differences, the χ2 test for qualitative variables was used. Likewise, the odds ratio (OR) was calculated to investigate the association between socio-demographic variables and the cephalometric features present in the malocclusion. A significance ≤ 0.05 was used.
Ethical considerations: The ethical considerations established in the Declaration of Helsinki were met, and the research was classified as risk-free. The research was approved by the Ethics Committee of the Research Centre of the Faculty of Odontology of the University of Antioquia, by Act No. 07 july 27, 2018.
RESULTS
From a total of 467 patients, 76 females and 64 males were selected. The majority were young people (46.2%) and from low and low-middle status (91.4%) (Table 1).
When the sagittal classification of malocclusion was related to socio-demographic factors, presence of oral habits and motive for consultation, class II was found to be the most prevalent, with a predominant vertical pattern, hyperdivergent for females and hypodivergent for males, young people and those of low and low-middle status.
In addition, a significant relationship was found between the vertical classification of malocclusion (hypo, normo and hyperdivergent) with oral habits (sucking habits [p = 0.019], atypical swallowing [p = 0.045] and mouth breathing [p = 0.036]). OR evaluated the associations between socio-demographic and cephalometric variables with sagittal characteristics (class I, II and III) and with vertical characteristics (hypo, normo and hyperdivergent). When quantifying the associations, class III malocclusions were found to occur four times more often than other malocclusions because of occlusal problems (p = 0.013) (OR = 4.09; CI 95% 1.5-11.1) (Table 2). Apart from that, great variability was found in the maxillomandibular characteristics for the three vertical types (p > 0.05) (Table 3).
The analysis of characteristics of the sagittal and vertical maxillomandibular relationship (Tables 4 and 5) yielded the following results:
- • Class I: orthognathic mandibular position predominated (42.9%) (p = 0.040) and prognathic maxilla (42.9%), with upper incisor prognathic (67.9%) with no statistically significant differences between them.
- • Class II: predominantly maxillary prognathism (54.7%) (p = 0.000) and retrognathic mandibular position (43.8%) (p = 0.000), and upper and lower incisor proclined (56.3% and 54.7% respectively) (p = 0.004).
- • Class III: with prognathic mandibular (85%) (p = 0.000) and orthognathic maxillary (45%) position and upper incisor proclined (85%) and lower incisor retroclined (70%) (p = 0.000).
- • Hyperdivergent: 51% of patients had orthognathic maxilla and 56.9% mandibular retrognathism.
- • Hypodivergent: a higher prevalence of maxillary prognathia (p = 0.000) and mandibular prognathia (p = 0.000) and lower incisors proclined (p = 0.004) was found. Moreover, an association was found between sagittal malocclusions and mandibular position (p = 0.000) (Table 4).
DISCUSSION
Cephalometric, sociodemographic characteristics and their associations have been studied in various populations.1,13 The present study sought to describe the cephalometric characteristics of patients from the postgraduate and their association with socio-demographic factors.
Sociodemographic characteristics. The highest prevalence corresponded to young people who consulted mainly for aesthetic reasons, of low and low-middle socioeconomic status. Similar results have been found in other studies regarding the type of population studied.2,13 The social characterisation carried out in different services suggests that, due to low purchasing power, patients go to university services that are cheaper.13 Additionally, the ENSAB IV (National Oral Health Study) found a predominance of strata 1 to 3 in the Antioquia region.14
On the other hand, aesthetics appears as the main reason for consultation, in agreement with several authors.1,15 There seems to be a consensus in several studies on the impact of malocclusion on the aesthetic perception of individuals.16-18
With regard to age, it seems that young people tend to be more concerned with the aesthetic canons imposed by society.1,19 Our findings are in agreement with these studies, as the majority of patients seeking orthodontic treatment were young.
On the contrary, class III patients consulted for functional problems (OR = 4.09; CI 95% 1.5-11.1), possibly because they are more aware of the functional problem of their malocclusion, as indicated by the studies of Montalvo et al, Xue et al, and Centofante et al.20-22
Cephalometric characteristics. In the present study the most prevalent malocclusion was class II with maxillary prognathism, retrognathic mandibular position and upper and lower incisors proclined; coinciding with McNamara23 and Stahl et al24 who observed a high frequency of mandibular retrognathism in class II. In contrast, Stahl et al found lower incisors retroclined, while Brezniak et al and Klocke et al found the maxilla orthognathic and the mandibular body relatively short, with retrognathic parameters.25,26
The above suggests that class II is very frequent, however, the patterns and characteristics do not have a single established pattern and there are differences according to the population studied. Which is also related to studies that state that class II malocclusion is the most frequent dentoskeletal disharmony in the white population and are the highest percentage who seek consultation for treatment.27
Our results differ from other authors who found class I with both maxillary profiles to be biprotrusive.28 Skeletal variations may occur alone or accompanied by dentoalveolar compensation.
We agree with the studies that found class III due to mandibular prognathism, with an orthognathic maxilla.29-31 McNamara et al reported that class III was more common due to mandibular prognathism and maxillary retrusion.32 Different studies state that the most common feature of class III is the prognathic mandible.33,34
The hyperdivergent vertical pattern was more prevalent in class II patients, similar to that reported by Brezniak et al.25 The finding is in agreement with those who have described that excessive vertical development is a frequent feature of this malocclusion, and may be a manifestation of impaired respiratory function.23,27,35 In contrast, Saltaji et al reported that the hypodivergent pattern was dominant in class II, division 2.36
In our study we found different dental compensations. In class II the most frequent were lower incisors proclined and in class III, upper incisor proclined and lower incisor retroclined. This is similar to other studies that find that dental compensation exists to camouflage the anteroposterior and vertical discrepancy of the bone bases and that the degree of compensation depends on the patient's individual response.37,38
A statistically significant relationship was found between the vertical classification of malocclusion (hypo, normo and hyperdivergent) with oral habits (sucking habit, atypical swallowing and mouth breathing). The literature states that the presence of these habits is related to mandibular rotation, suggesting an aetiological role of oral habits in vertical dysplasias. So it becomes necessary for further studies to classify patients vertically by habits to observe whether or not they contribute to facial hyperdivergence.39-42
Clinical implication. "Orthodontic treatment planning within a public health system requires information on the prevalence and distribution of malocclusions",43 therefore it is important for the clinician to be aware of the prevalence of malocclusions and sociodemographic characteristics of their study population.
CONCLUSIONS
According to the cephalometry the majority of patients were class II and normodivergent. The cephalometric characteristics of the malocclusions were highly variable with statistically significant differences between them.
The majority of patients were young people of low and low-middle social status, unemployed or self-employed and these characteristics did not influence the malocclusion.
Oral habits were related to vertical malocclusions.
The main reason for consultation was aesthetic.
Class III patients seemed to be more aware of their functional problems.
ACKNOWLEDGEMENTS
To the IMAX Radiology Centre for their collaboration and diligence.
REFERENCES
AFFILIATIONS
1 Especialista en Odontología Integral del Niño. Profesor Titular. Universidad de Antioquia, Facultad de Odontología. Medellín, Colombia.
2 Especialista en Estomatología Pediátrica. Especialista en Odontología Integral del Adolescente y Ortodoncia. Magister en Educación y Desarrollo Humano. Profesor Titular. Universidad de Antioquia, Facultad de Odontología. Medellín, Colombia.
3 Especialista en Odontología Integral del Niño. Especialista en Odontología Integral del Adolescente y Ortodoncia. Profesor Titular. Universidad de Antioquia, Facultad de Odontología. Medellín, Colombia.
4 Estudiante de Posgrado Ortopedia Maxilar. Universidad de Antioquia, Facultad de Odontología. Medellín, Colombia.
CORRESPONDENCE
Lucia V Bernal. E-mail: luciavictoria25@gmail.comReceived: Febrero 2021. Accepted: Septiembre 2021.