Download Orthodontic treatment need and malocclusion prevalence in Turkish

Balkan Military Medical Review
BALKAN
Military Medical
REVIEW
10, 107-113 (2007)
Original Article
Orthodontic treatment need and malocclusion prevalence in Turkish adult males
Sari E1, Kurtulmus H2, Boyacioglu H3
Kasimpasa Military Hospital, Department of Orthodontics1, Istanbul, Turkey
Ege University Faculty of Dentistry, Department of Prosthodontics2, Izmir, Turkey
Ege University Faculty of Sciences, Department of Statistics3, Izmir, Turkey
Abstract: The purpose of this study is to assess the
objective and subjective levels of orthodontic
treatment needs and severity of malocclusion in
Turkish male adults considering the effect of
regional variation. A sample of 556 adult males
(median age of 21 years) from 7 different regions of
Turkey have been subject to this study. The Index of
Orthodontic Treatment Need (IOTN) was used to
evaluate
the
orthodontic
treatment
need.
Questionnaires were used to evaluate the perception
of malocclusions and the benefit of orthodontic
treatment of subjects. Forty-seven percent of
subjects had definite need of orthodontic treatment
based on dental health component (DHC) of IOTN.
Severe contact point displacement (4d-14%) was the
most frequently encountered occlusal traits in the
sample. 63.3% of subjects had no need of treatment
according to the subjective esthetic component (EC)
of the IOTN whereas, 59% of subjects had no need
treatment based on objective EC of the IOTN. South
East region had the highest proportion with no
treatment need based on objective EC (p=0.036). It is
found a good correlation between objective and
subjective EC (p=0.614). Turkish male adult could
evaluate the objective orthodontic treatment need.
Most of the subjects (64%) did not demand the
orthodontic treatment in this study. Class I (51%)
was the most frequently seen malocclusion type in
these subjects.
Key words: Orthodontic treatment, malocclusion,
adult.
____________________________________________
The physical attractiveness and a pleasing smile
reflect positive status at all social level, however,
irregular teeth and protruding might lead to negative status [1,2]. On previous studies on the perception of malocclusion, it was found that adults were
generally more aware of the arrangement of anterior occlusal traits than buccal segments. Among
the anterior occlusal traits of major concern in
adults were anterior crowding, rotations and overjet [3,4]. Men were generally more satisfied with
their dental appearance and less likely to perceive a
need for orthodontic treatment to correct their malocclusions than women [5].
Several studies in various populations were examined by using IOTN [6-9]. The results showed that
there was an orthodontic treatment need at least in
one-third of the population. IOTN comprises a
DHC and EC [10]. The EC has a scale of 10 colored photographs showing different levels of dental attractiveness, grade 1-4 represent no or little
aesthetic need, grades 5-7 borderline aesthetic need
and grades 8-10 a definite aesthetic need for orthodontic treatment. DHC has 5 grades; grades 1-2
represent no need for treatment, grade 3 represents
borderline cases and grades 4-5 represent very
great need. Both components help to identify those
persons who would be most likely to benefit from
orthodontic treatment. The IOTN has been shown
to be valid and reliable [11,12].
Data concerning the IOTN and malocclusion type
in adults are available for many populations
[1,9,13-16]. However no such data are available
for Turkish adults. On the other hand several studies showed that gender, socio-economic level and
age could affect the orthodontic treatment need
[1,2,8]. There is no such data which evaluates correlation between the variety of food consumption
and orthodontic treatment need in a country.
Turkey is very large country and divided into
seven regions. These geographical regions were
separated according to their climate, location, flora
and fauna, human habitat, agricultural diversities,
transportation, topography and so on. Four outer
regions and 3 inner regions were named according
to their neighborhood to the four seas surrounding
Turkey and positions in Anatolia. The name of the
Correspondence to: Emel Sari, Med Dent, PhD, e-mail: [email protected]
Sari et al.: Orthodontic treatment and malocclusion in Turkish adult males
regions are Eastern Anatolian, Central Anatolia,
Black sea, Mediterranean, Aegean, Marmara and
South-East Anatolia.
Accustom of food consumption changes according
to different seven climatic region of Turkey in
population. Wheat and wheat products are usually
consumed in east and southeast region of Turkey,
vegetable and fruit in Aegean, liquids in Marmara
and Central Anatolia region. Socio-economic differences also change according to regions. Marmara and Aegean region are very similar regions
based on their high socio-economic level in contrast to other regions. Education and income are
also high in those regions when compared to other
regions [17].
The aim of this study was to determine the level of
objective and subjective orthodontic treatment
need in population coming from different regions
of Turkey, self-perception of dental attractiveness
and frequencies of different types of malocclusions
of Turkish male adults.
Materials and methods
A total of 556 male (a median age of 21) Navy
recruits with no history of orthodontic treatment,
serial extractions and craniofacial anomalies
evaluated in this study. The subjects were subgrouped according to seven different regions in
Turkey. Informed patient consent was obtained as
part of the routine clinical procedure. Impressions
were taken from all subjects as a study model. The
severity of malocclusions was evaluated into four
categories according to the following criteria:
Class I group: Class I soft tissue profile positive
overjet up to three mm. Angle Class I molar relationship in centric occlusion.
Class II division 1 group: Convex soft tissue
profile excessive overjet (more than 3 mm), protrusive maxillary incisors, Angle Class II molar relationship in centric occlusion.
Classs II division 2 group: Decreased anterior
facial height: excessive overbite (more than 3 mm)
retroclination of two or more maxillary incisors,
Angle Class II molar relationship in centric occlusion.
Class III group: Concave soft tissue profile; negative overjet in all anterior teeth; Angle Class III
molar relationship in centric occlusion.
IOTN with two parts, EC and DHC components,
was used in order to estimate the objective and
108
subjective treatment need in participants of this
study. In order to determine the subjective orthodontic treatment and self perception of dental attractiveness, each participant were asked to identify which photograph of EC scale most closely
matched the appearance of their anterior teeth. On
the other hand to evaluate the demand for orthodontic treatment, each participant was asked some
questions about what the benefits of orthodontic
treatment and if they have any desire for orthodontic treatment in future.
Severity of malocclusion and orthodontic treatment
need were evaluated by a single examiner. To test
the intra examiner agreement, 30 randomly selected study models were re-examined 6 weeks
after the initial examination.
Statistical Analysis
In the first part of statistical analysis, kappa ( k )
statistics is used to determine the agreement, the
objective and subjective between DHC and EC
assessments. In the second step, Chi-square test
was applied to determine the differences between
the orthodontic treatment need and regions in Turkey. In the third step, analysis of variance
(ANOVA) is used to assess whether the variability
of the DHC grade means. In the last step, objective and subjective EC were assessed with Spearman rank correlation analysis. In all tests, a was
accepted as 0.05. Data analysis was performed
using SPSS 10.0.
Results
Evaluation of intra-examiner reproducibility
The Kappa values of the intra-examiner reproducibility for the DHC and EC were ( = 0.87, p<0.05)
and ( = 0.74, (p<0.05), respectively. It represented
a good agreement.
Evaluation of dental health component in the
regions of Turkey
It shows the distriubution of dental health component scores of sample in Figure 1. One-hundred
and fifty-two male adults (27.3%) had no aesthetic
need (grade 1-2), 140 male adults (25.2%) had a
border line need (grade3) and 264 male adults
(47.5%) had need for definite treatment (grade 45). There was no statistical difference among DHC
grades (p=0.19, >0.05).
The distribution of DHC grades and qualifiers was
shown in Table 1. Severe contact point displacement (4d-14%) was the most frequently encoun-
109
Balkan Military Medical Review
Vol. 10, No. 3, July 2007
0.50
Percentage
0.50
0.40
0.25
0.30
0.20
0.12
0.13
0.10
0.03
0.00
1
2
3
4
5
DHC Grades
Figure 1. Distribution of objective dental heath component scores of samples, n=556.
Table 1. Distribution of DHC scores and qualifiers of
samples, n=556.
DHC Scores
Grade
Qualifier
1
Total
2
A
B
C
D
E
G
Total
3
A
B
C
D
E
F
Total
4
A
B
C
D
E
F
H
M
T
Total
5
M
Total
Frequency
66
66
8
8
16
42
8
4
86
23
32
8
12
24
42
141
54
36
29
76
12
32
4
%
0,12
0,12
0,01
0,01
0,03
0,07
0,01
0,01
0,15
0,04
0,06
0,01
0,02
0,04
0,07
0,25
0,10
0,07
0,05
0,14
0,02
0,06
0,01
The distribution of objective and subjective EC
scores are illustrated in Figure 2 and 3. According
to objective EC 59% had no aesthetic need (grade
1-4), 18% a borderline need (grades 5-7), 23%
adult males had a definite aesthetic need (grades 810) for treatment. On the other hand the distribution of subjective EC scores in Turkish male adults
had 63.3% no aesthetic need (grade 1-4), 21.6%
had a border line need (grades 5-7), and 15.1% of
adult males had a definite aesthetic need (grades 810) for treatment. The main descriptive difference
is clear at no and borderline need levels for
treatment in both objective and subjective EC.
Central Anatolia (5%) and Aegean Region (5%)
had the highest proportion with the definite treatment need in contrast to South East Region
(12.2%), which had highest proportion with no
need treatment among the other regions of Turkey
based on objective EC. This result is found statistically significant (p=0.036, <0.05). On the other
hand Aegean Region 3.6% had the most definite
treatment need according to subjective EC in Turkey. This result is not statistically significant
(p>0.05).
Objective Assessment
0.25
0.20
0.20
Percentage
Distribution of Objective DHC Scores
0.60
Evaluation of Esthetic Component
0.16
0.15
0.12
0.12
0.09
0.10
0.05
1
2
3
4
0,01
0,46
0,02
0,02
0.04
6
7
5
0.05
8
9
10
Scale
Figure 2. Distribution of objective esthetic component
scores of samples in Turkey.
Subjective Assessment
0.30
0.26
0.25
0.20
0.15
0.14
0.14
0.14
0.09
0.10
0.07
0.06
0.05
8
251
12
12
0.09
0.08
0.04
0.00
Percentage
tered occlusal traits in the sample. There was no
significant difference among the regions of Turkey
in the distribution of DHC (p=0.28, >0.05).
0.04
0.04
0.02
0.00
1
2
3
4
5
6
7
8
9
10
Scale
Figure-3. Distribution of subjective esthetic component
scores of samples n=556.
Sari et al.: Orthodontic treatment and malocclusion in Turkish adult males
110
Comparison of objective and subjective EC
Evaluation of malocclusion severity
Figure 4 shows the comparison of objective and
subjective EC assessment. The subjective treatment need was correlated with objective treatment
need according to EC assessment (r= 0.614,
p<0.05).
The distribution of malocclusions according to
regions in Turkey is shown in Figure 5. Class I
malocclusion was found in 218 patients which
represented 51 % of sample. The frequency of
Class II division I and Class II division II malocclusion were 26% and 10%, respectively. 13% of
total samples had Class III malocclusions.
0,3
0,25
0,2
objective
0,15
subjective
0,1
CL III
13,0%
CL II DIV II
10,0%
0,05
0
CL I
1
2
3
4
5
6
7
8
9
10
51,0%
Figure 4. Comparison of subjective and objective esthetic component assessments.
CL II DIV I
26,0%
Perceived benefit of orthodontic treatment and
dental esthetic
Table 2 shows the frequencies of the questions,
subjective need on dental aesthetic and desire for
orthodontic treatment and benefits of orthodontic
treatment. 43% of sample perceived their own
teeth needed orthodontic treatment. However 25%
of adults thought their teeth well aligned and 32%
male adults were indecisive. Sixty-four percent of
the participant did not consider wearing braces.
Fifty-two percent of participants perceived the
orthodontic treatment related to the improvement
of dental aesthetic rather than masticator and
speech function.
Table 2. Perceived dental esthetics and treatment
need; perceived benefits of treatment
Perceived dental aesthetic and desire
for orthodontic treatment
% response
Yes
No
Not
Sure
Do you think that you have a well
25
43
32
aligned teeth
Do you think to wear braces
22
64
14
Perceived the benefits of treatment
What do you think the benefits of rthodo
% response
treatment
To have nice looking set of teeth when
52
I smile
To be able to chew
12
To be able to talk better
8
Not sure
28
Cases weighted by DHC
Figure 5. Distribution of malocclusion severity of samples.
Discussion
The malocclusion types and orthodontic treatment
need is examined in Turkish male adults in this
study. Several studies about self perception of
malocclusions [1,4,5,8,9,13,14] showed that male
adults and older men did not aware of their dental
attractiveness like females. But Burden and Pine
[18] concluded that gender has no influence on the
uptake of orthodontic treatment. In our study it was
found that Turkish male adults were satisfied with
their anterior dental appearance according to the
results of EC of IOTN.
According to the objective EC of the IOTN Turkish male adults had no need of treatment (59%).
This finding was similar to Asian adults and British children [9,18].When British and Asian adults
was evaluated by EC of IOTN, highest percentage
of subject did not need treatment to improve dental
appearance (53% and 42.7%, respectively). On the
other hand, 60% of Tanzanian children had not any
slight need of treatment based on EC of IOTN [1].
Besides Jordan, Nigerian children and Finland
young adults were reported a lower need for treatment [19,20].
111
In the present study, 63.3% of the male adults perceived their teeth more attractive according to subjective EC. This finding is close to objective EC of
IOTN. This indicated that Turkish male adults can
make objective evaluations of their teeth. This was
not correlated with questionnaire responses. Only
25% of adults perceived themselves to have a wellaligned tooth. It showed that the subjects did not
know whether they need orthodontic treatment. On
the other hand 64% of subject did not want to wear
braces. This could be due to that male did not express much dental esthetic concern as reported in
the literatures [17,19].
It is known that etiologic factors including specific
causes of malocclusion (disturbances in embryologic and dental development, skeletal growth disturbances, acromegaly and hemimandibular hypertrorphy, trauma to teeth, hereditary influences, and
environmental influences) affect to become malocclusions. Environmental influences during growth
and development of the face and teeth consist
largely of pressures and forces related to physiologic activity. For example; how the person chew
and swallow, what the person eat, pressures against
jaw and teeth could affect how jaws grow and teeth
erupts. In addition, chewing exercise and other
forms of physical therapy should be an important
part of orthodontic treatment. Wheat and wheat
products are required to long term chewing
whereas fruit and vegetables are required for short
time chewing [22].
The most definitive treatment need based on objective EC of IOTN among the regions of Turkey was
Central Anatolia Region (5%) and Aegean Region
(5%). This could be the result of genetic, habit of
food consumption, education and socio-economic
differences. Population living in this area usually
consumes vegetable and fruit in contrast to Southeast (12%) regions of Turkey. Wheat and wheat
products are composed of heavy fibrouses caused
the abrasion of proximal areas of teeth avoiding the
malocclusion severity. It could be concluded that
orthodontic treatment need was low in Southeast
region of Turkey since the population living this
area consume more wheat and wheat products than
the other regions.
When the DHC of IOTN was assessed, 47% of
male adults had great need for orthodontic treatment which included grade 4 and 5 in this study.
Ugur et al. [22] s study resulted 52.6% need for
treatment in Turkish 572 primary school children.
However, they used TPI, examined 500 Turkish
school children by using IOTN, DHC scores were
Balkan Military Medical Review
Vol. 10, No. 3, July 2007
found as 38.8% definite need for orthodontic
treatment in the study [23]. In our study, definite
need percentage in Turkish male adults was similar
to Ugur et al. s study. On the other hand Soh et al.
[9] assessed the 339 Asian male adults. It was reported that fifty percentage of sample had definite
need for orthodontic treatment. This result was
similar to our study.
However, when the results of EC and DHC of
IOTN were evaluated, it was observed there was
no correlation between the treatment need scores.
While 53% of samples had need treatment definitely in DHC of IOTN, 22% of samples had definite treatment need according to objective EC of
IOTN. Mandal et al. [24] reported an association
between child esteem and IOTN EC but not with
IOTN DHC. On the other hand, EC is more subjective and less reliable than the DHC, studies which
compared the need based on the two components
demonstrated poor correlation [25,26].
Seventy-six subjects (14%) had malocclusion with
DHC grades 4d, which meant that they had severe
contact point displacement. Subjects with DHC
grade 4a (11%) had overjet greater than 6 mm.
Besides the subject with DHC grade 4b (7%) had
reverse overjet greater than 3-5 mm. These findings, including both 4a and 4b showed a correlation with the Class I malocclusion types which
mostly encountered in Turkish male adults in this
study.
In our study, the results indicated that Class I was
most frequently seen malocclusion (49%) in Turkish. The frequencies of Class II division I and
Class II division II were 26% and 10% respectively. Class III malocclusion was observed in 13%
of subjects. Sari et al. [27] evaluated 1602 Turkish
patients. They reported that 61.7% of patients had
Class I, 25.1% had Class II division, 13.0% had
Class II division II, and 10.2% had Class III malocclusion. Our findings are close to Sari et al s
study but differ from Sayin et al s finding [28] who
reported that 64% had Class I, 19% had Class II
division, I5% had Class II division II and 12% had
Class III in 1356 patient.
Class II division II was the most encountered malocclusion (31%) in Black Sea region among the
regions. Additionally Class I was the most common malocclusion in all regions of Turkey. On the
other hand, the high level of 4d, 4a and 4b in DHC
of IOTN showed a correlation with malocclusion
types. The most frequently seen malocclusion is
Class I whereas 4d had high percentage (14%) in
great need treatment level. This is observed in
Sari et al.: Orthodontic treatment and malocclusion in Turkish adult males
similar way at 4a (11%) and Class division I and
also 4b and Class III malocclusions.
Conclusion
In our study, it was found that Turkish male adults
showed a high level of definite need for objective
112
orthodontic treatment. Turkish male adults could
evaluate the objective need for orthodontic treatment. But most of the subjects did not demand the
orthodontic treatment in this study. Dental discrepancies and Class I malocclusion were the most
common occlusal trait in Turkish population.
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