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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. References 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. Mugonzibwa EA, Kuijpers-Jagtman AM, Van t Hof MA, Kikwilu EN. Perceptions of dental attractiveness and orthodontic treatment need among Tanzanian children. Am Am J Orthod Dentofacial Orthop 125:426-433, 2004. Klages U,Bruckner A, Guld Y, Zenter A. Dental esthetics, orthodontic treatment, and oral health attitudes n young adults. 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