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Prevalence of malocclusion in the early mixed dentition and orthodontic

treatment need

Article  in  The European Journal of Orthodontics · July 2004

DOI: 10.1093/ejo/26.3.237 · Source: PubMed

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European Journal of Orthodontics 26 (2004) 237–244 European Journal of Orthodontics vol. 26 no. 3
 European Orthodontic Society 2004; all rights reserved.

Prevalence of malocclusions in the early mixed dentition

and orthodontic treatment need
Eve Tausche, Olaf Luck and Winfried Harzer
Department of Orthodontics, Technical University of Dresden, Germany

SUMMARY Early interceptive treatment for the elimination of factors inhibiting dental arch development and
mandibular and maxillary growth is applied varyingly by orthodontists, possibly because there is little
scientific evidence that such interventions are of actual benefit. The aim of this study was to determine
specific factors for treatment need in the early mixed dentition period in order to obtain basic data to sup-
port early intervention. The study was part of a larger survey of 8768 children aged between 6 and 17 years.
From this sample, 1975 children aged between 6 and 8 years were used to estimate the prevalence of mal-
occlusions using the Index of Orthodontic Treatment Need (IOTN) during the early mixed dentition period.
The results showed that deep overbite and overjet, both more than 3.5 mm, were the most frequent
discrepancies, affecting 46.2 and 37.5 per cent of patients, respectively. An anterior open bite was
registered in 17.7 per cent, crossbite in 8.2 per cent, and a reverse overjet in 3.2 per cent. A tooth width
to arch length discrepancy was recorded in 12 per cent of teeth in the upper arch and in 14.3 per cent
in the lower arch. The proportion of children estimated using the Dental Health Component of the IOTN
to have a great or very great treatment need (grades 4 and 5) was 26.2 per cent. The higher values of
treatment need during the mixed dentition period may account for temporary changes in the dentition
and for the discrepancy in overjet and overbite. These discrepancies will be compensated in part during
mandibular growth and development of the dental arch. Nevertheless, the findings indicate the early
development of progressive malocclusion symptoms which are evidenced in the IOTN and concur with
the acronym ‘MOCDO’ hierarchy (missing, overjet, crossbite, displacement, overbite). This early formation
of progressive symptoms inhibiting or disturbing mandibular or maxillary growth or the development of
the normal dental arch, i.e. crossbite, reverse overjet and increased overjet with myofunctional dis-
orders, should be treated at an early stage.

Introduction study in children aged between 7 and 14 years and

recorded an increased severity of Class II malocclusions,
Treatment of dental crowding and malocclusions is more pronounced in mild than in severe cases compared
normally initiated after referral of a child at the age of with the baseline status. Crossbite is one form of
10–12 years, i.e. during the second period of the mixed malocclusion requiring early treatment. A posterior
dentition when a canine erupts or an increase in overjet crossbite has increased more in industrialized countries
becomes noticeable to the patient and parents. Initiation than in developing countries and affects between 8 and
of treatment at this time may be indicated in subjects 13 per cent of nursery school children (Yamasaki et al.,
with moderate crowding but without bite anomalies. 1989; Kerosuo, 1990; Bergström et al., 1998; Ghabrial
However, patients with discrepancies in occlusion, et al., 1998). Sonnesen et al. (2002) reported an
impairment of voluntary movement, and abnormalities asymmetric development of masticatory muscle function
in tooth number require earlier intervention (Miotti, in children with unilateral crossbite.
1991). In these cases, early intervention performs a A further reason for early treatment is the prevention
similar function to interceptive orthodontics by preventing of tooth trauma in patients with Class II malocclusions,
progression to the full form of a given disorder and with an increased overjet and upper incisor inclination
excluding factors interfering with the regular development (Harzer et al., 1998).
of the dental arches. For estimation of the need for early intervention, data
The disadvantage of an early start is the long treatment on the incidence of malocclusions and their progression
period with diminishing compliance and uncertain growth is required, together with information on the validity of
prediction. On the other hand, age-related increases in treatment need (Foster, 1980). There are still insufficient
the severity of crowding and in arch length discrepancies reliable data on the negative functional and psychosocial
with incisor proclination in Class II malocclusions may effects of malocclusion to permit true scientific validation
justify early treatment (Anders et al., 2000). Ingelsson- of different indices of orthodontic treatment need
Dahlstrom and Hagberg (1994) carried out a longitudinal (Burden and Holmes, 1994).
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238 E . TAU S C H E E T A L .

The Index of Orthodontic Treatment Need (IOTN), Table 1 Distribution of the 1975 subjects related to
with the Dental Health Component (DHC) and the chronological age between 6 and 8 years.
Standard Component of Aesthetic Need (SCAN), is the
most frequently used tool for measuring treatment need 6 years 7 years 8 years Total Per cent
(Evans and Shaw, 1987; Brook and Shaw, 1989;
Firestone et al., 1993; Kisely et al., 1997; Breistein and Female 133 414 458 1005 50.9
Male 128 403 439 970 49.1
Burden, 1998). This index was developed on the basis of
all currently available scientific data and concurs with
a broad consensus of professional opinion in the UK
where it was developed. In most cases the DHC is Shaw, 1989) and is an internationally acknowledged
used to differentiate between ‘need’ and ‘no need’. The scoring system for treatment need as perceived by the
SCAN alone is unsuitable for screening treatment professional and the patient (Lindauer et al., 1998).
need but is a stronger indicator of patient satisfaction Apart from morphological discrepancies, this index also
(Crowther et al., 1997). Apart from overall treatment registers functional disorders and gives a systematic
need, characteristics of the IOTN comprise the order for a hierarchical scale. Considerations as to no
hierarchy of single symptoms. The acronym ‘MOCDO’ treatment need, borderline need, or great need are based
(missing, overjet, crossbite, displacement, overbite) on five-grade (DHC) and 10-grade scales (SCAN)
means that missing teeth and overjet, including reverse (Figures 1 and 2).
overjet, have the highest priority in the assessment As the time factor may be a priority when considering
of treatment need. The hierarchical scale was designed treatment need in terms of safeguarding normal
for the purpose of providing a guide for systematic development of the dental arches, an urgent need for
examination, with the examiner recording and focusing intervention was specified for certain anomalies such as
the treatment activity to the higher evaluated anomaly reverse overjet or crossbite as early as 6–8 years of age,
in the case of two or more occlusal anomalies (Richmond and the children’s parents were informed accordingly.
et al., 1994). In most studies the IOTN has been used in Richmond et al. (1994) state that displacement of
children in the late mixed or full permanent dentition. contact points should not be measured between the
The measurement of orthodontic treatment need is thus primary and permanent teeth. Therefore, crowding was
not only a question of the severity of malocclusion traits measured as the tooth width to arch length discrepancy
but also of age, dentition period and growth acceleration. and was recorded as anterior and posterior crowding.
Different morphological and functional factors are Calibrated data recording is important for the
involved in the early inhibition of growth and develop- application of the IOTN and for its validity and repro-
ment. This must be taken into account when using the ducibility. The DHC data were recorded simultaneously
IOTN (Crowther et al., 1997; Breistein and Burden, at the schools by two authors who had undergone
1998; Mauck and Tränkmann, 1998; Tarvit and Freer, extensive instruction. To test intra-examiner reproducibility,
1998). The aim of this study was to estimate the 20 children were re-examined 4 weeks after their initial
prevalence of malocclusions using the IOTN during the examination (kappa 0.78). The SCAN was evaluated by
early mixed dentition period to provide basic values for one calibrated postgraduate student (ET), with a kappa
the benefit of early orthodontic intervention and to value of 0.81 being recorded. Kappa values above 0.6
review the hierarchical system against this background. indicate substantial agreement (Landis and Koch, 1977).

Materials and methods Results

The overall investigation was planned as a cross-sectional Differentiation in the age group from 6 to 8 years
study with continuation as a longitudinal investigation. was based on the allocation of developmental stages,
In 1996 and 1997 a sample comprising 8768 Dresden because the start of treatment was to focus on the
schoolchildren was drawn from the 65 000 in the city of dentition rather than on age (Figure 3). In the study
Dresden (population: 470 000). From this population, group as a whole, the first period of the mixed dentition
1975 children (970 boys and 1005 girls) aged between with eruption of first molars and incisors was dominant,
6 and 8 years 11 months formed the sample for the although with a wide inter-individual range.
investigation of treatment need in the early mixed The prevalence of the malocclusions are listed in
dentition (Table 1). Tables 2–5. An open bite with ranges from 1 to 12 mm was
Fifty features were evaluated together with a profile recorded in 17.7 per cent of the children. Deep bite with
photograph and a close-up of the mouth. and without gingival contact was registered in 46.2 per
The findings served to determine orthodontic treatment cent (Table 2). Crossbite was found more frequently on
need with reference to the IOTN. This consists of the the right than the left side, but occurred on both sides
DHC and the SCAN (Evans and Shaw, 1987; Brook and in 7.7 per cent. Scissors bite was rare, being recorded
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O RT H O D O N T I C N E E D I N T H E M I X E D D E N T I T I O N 239

Figure 1 Index of Orthodontic Treatment Need: morphological and functional symptoms in the five grades (1 and 2 = no
need; 3 = borderline need; 4 and 5 = great/very great need) of the Dental Health Component.

in only 0.5 per cent of the children (Table 3). A Class III In this early mixed dentition group (first period), the
malocclusion (skeletal) with reverse overjet was found IOTN revealed an urgent treatment need in 26.2 per
in 3.2 per cent (Table 4). Overjets ranging from 0.5 to cent using the DHC (greater than or equal to grade 4)
14.0 mm were recorded, with an overjet greater than and in 21.5 per cent with the SCAN (greater than or
3.5 mm (Class II division 1) being registered in 31.4 per equal to grade 8) (Figures 5 and 6). When the borderline
cent of cases (Table 4). Anterior crowding greater than cases were taken into consideration, the treatment need
3 mm was recorded in the mandible in 14.3 per cent increased to 51.7 per cent with the DHC and to 66 per
of subjects and in the maxilla in 12 per cent (Table 5, cent with the SCAN. Between the ages of 9 and 11 years,
Figure 4). the treatment need according to the IOTN–DHC and
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240 E . TAU S C H E E T A L .

establishment of a relationship between the registered

onset of orthodontic treatment and disorders inhibiting
growth of the alveolar bone and development of the
dentition reflects, on the one hand, the lack of validity of
the indices used to estimate treatment need but, on the
other hand, shows that most orthodontists fail to take
account of the potential progression of malocclusions at
this early stage (Figure 4). The lag effect is also reflected
in the proportion of children affected by crossbite,
mandibular prognathism and the presence of asymmetries
with a functional shift up to the age of 9 years.
At this point the hierarchical system of the IOTN
needs to be taken into consideration. The ‘missing
teeth’ priority should be focused on early diagnosis for
guidance of the dentition in cases of orthodontic space
closure. However, hypodontia cannot be investigated
without radiography. The high prevalence of overjet,
including reverse overjet, in this age group suggests that
trauma prevention in severe cases should be started at
an early stage. Kluemperer et al. (2000) showed that an
early treatment start may be effective and desirable in
specific situations, but should be decided on a case-
Figure 2 Index of Orthodontic Treatment Need: Standard
by-case basis, bearing in mind that an open bite and
Component of Aesthetic Need with 10 grades (1–4 = no need;
5–7 = borderline need; 8–10 = great need). increased overjet are known to diminish with the
elimination of thumb sucking and other habits. This
including grade 3 (moderate or borderline cases) was reduction through the elimination of habits, permanent
45 per cent. When grade 3 was disregarded, the treatment mouth breathing and other environmental factors is
need was reduced by approximately 20 per cent (Figure 7). not uniform. On the other hand, the same applies to
increased severity of the malocclusion. Crowther et al.
(1997) found that progression was less pronounced in
Discussion
younger children with large overjets than in those with
The development of the dentition in children aged moderate overjets. Early treatment should depend on
between 6 and 8 years is characterized by a wide range the severity of the malocclusion and its impact on the
of variations. Figure 3 shows that this variability neuromuscular system, i.e. disturbed lip function and
concerned both the eruption of teeth and their permanent mouth breathing. In the present study,
alignment. Obviously this was paralleled by an age- 6.3 per cent of the children had an overjet greater than
related variation in the development of disorders. The 6.1 mm, resulting in these dysfunctions. In cases of

Figure 3 Distribution of developmental stages in 1975 schoolchildren aged between 6 and

8 years.
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O RT H O D O N T I C N E E D I N T H E M I X E D D E N T I T I O N 241

Table 2 Prevalence of anterior open bite and deep overbite Table 5 Distribution of maxillary and mandibular crowding
in 1975 children aged between 6 and 8 years. in 1975 schoolchildren aged between 6 and 8 years.

Frequency (n) Per cent Upper anterior Lower anterior

crowding crowding
Anterior open bite
None 1626 82.3 No crowding 1354 (68.6%) 1045 (52.9%)
1–3 mm 294 14.9 Mild (0–2 mm) 384 (19.4%) 648 (32.8%)
4–6 mm 47 2.4 Moderate (3–4 mm) 201 (10.2%) 251 (12.7%)
Greater than 6 mm 8 0.4 Severe (greater than 4 mm) 36 (1.8%) 31 (1.6%)
Total 1975 100
Overbite
Less than 3.5 mm 1061 53.8
Increased overbite greater than 313 15.8 produces more favourable changes in older children,
or equal to 3.5 mm without and palatal expansion in cases of crossbite appears to
gingival contact
Deep overbite complete on gingival 315 15.9 be most effective and stable if initiated before the start
or palatal tissues but not trauma of ossification of the midpalatal suture (Enlow, 1966).
Increased and complete overbite 286 14.5 The timing of expansion should therefore focus on the
with gingival or palatal trauma
Total 1975 100 patient’s specific needs. Nevertheless, the functional
shift resulting from crossbite should be corrected at
an early stage in the interests of reducing or even
Table 3 Prevalence of crossbite and scissors bite in 1975 preventing asymmetric growth of the mandible and the
schoolchildren aged between 6 and 8 years. maxilla (Thilander et al., 2001). Sonnesen et al. (2002)
pointed out that crossbite occlusion supports the
Frequency (n) Per cent development of an asymmetric bite force.
There is a general consensus that treatment of crowd-
No findings ing should start in the permanent dentition. Gianelly
Right 1877 95.0 (2002) suggests intervention while the second primary
Left 1912 96.8 molars are still in function, in the interests of preventing
Crossbite
Right 92 4.7 arch length discrepancies. For application of the IOTN
Left 60 3.0 to the mixed dentition, the results of the present study
Scissors bite indicate that contact point deviation between teeth of
Right 6 0.3
Left 3 0.2 the primary and permanent dentition should not be
measured, i.e. this calculation should be deleted in the
application of the IOTN to the early mixed dentition.
Table 4 Prevalence of positive and negative overjet in 1975 The prevalence of deep overbite in the investigated
schoolchildren aged between 6 and 8 years. group was very high (46.2 per cent greater than 3.5 mm).
However, there was a difference in the combinations of
Frequency Per cent malocclusions. In the age range between 6 and 8 years,
deep overbite, increased overjet and open bite were
Reverse overjet (Class III) predominant, whereas crowding was the main factor
Less than –1 mm 10 0.5 in malocclusions in the permanent dentition. The main
Less than 0 mm but greater 17 0.9
than or equal to –1 mm reason for this change was the more pronounced man-
0 mm 36 1.8 dibular growth with reduced overjet and overbite. In a
Positive overjet (Class II) number of subjects, however, the severity of Class II
Greater than 0 mm but less than 1189 60.2
or equal to 3.5 mm
division 1 and Class II division 2 malocclusions increased.
Greater than 3.5 mm but less than 500 25.3 A combination of an overjet greater than 9 mm and deep
or equal to 6 mm overbite with gingival trauma should be treated early in
Greater than 6 mm but less than 99 5.0
or equal to 9 mm
order to prevent tooth fracture and to normalize lip
Greater than 9 mm 21 1.1 function. Myofunctional training to improve lip function
Missing* 103 5.2 and permanent nose breathing are the treatment goals
of an open bite in this age group.
*No measurement because incisors unerupted. The present investigation showed a great and very
great treatment need (DHC 4 and 5) in 26.2 per cent of
reverse overjet there is no doubt that early treatment children during the mixed dentition period, similar to
prevents asymmetric alveolar bone growth and disturb- that found in investigations in older age groups (Bishara
ances in the maxillary dentition (Kluemperer et al., et al., 1998; Proffit et al., 1998; Tarvit and Freer, 1998;
2000). The early treatment of Class III malocclusions Chi et al., 2000).
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242 E . TAU S C H E E T A L .

Figure 4 Distribution of malocclusion and occlusal anomalies in 1975 schoolchildren aged between
6 and 8 years.

Figure 5 Orthodontic treatment need in 1975 schoolchildren, Figure 7 Orthodontic treatment need and ongoing orthodontic
evaluated with the Dental Health Component of the Index of treatment in 8768 schoolchildren aged between 6 and 17 years
Orthodontic Treatment Need. (hatched area = 1975 schoolchildren aged between 6 and 8 years).

Although the IOTN measures the incidence of treat-

ment need and does not specify the stage at which
treatment should be carried out, the prevention of
progression is a justifiable reason for early treatment in
these cases (White, 1998; Pangrazio-Kulbersh et al.,
1999). Kluemperer et al. (2000) concluded that early
orthodontic treatment of these malocclusions may pre-
vent asymmetric alveolar bone growth and disturbances
in the permanent dentition. A second advantage is the
inhibition of progression and severity of the malocclusion
(Bishara et al., 1998). Crossbite and reverse overjet do
not diminish with age. The prevalence in the permanent
dentition reflects progression in severity and dysfunction,
so that early intervention aimed at preventing deterioration
and at stimulating well-balanced growth and occlusal
Figure 6 Orthodontic treatment need in 1975 schoolchildren,
evaluated with the Standard Component of Aesthetic Need of the development is indicated. In the overall sample of
Index of Orthodontic Treatment Need. 8768 schoolchildren aged between 6 and 17 years, the
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O RT H O D O N T I C N E E D I N T H E M I X E D D E N T I T I O N 243

frequency of orthodontic treatment coincided with the Bergström K, Halling A, Huggare J 1998 Orthodontic treatment
estimated treatment need as determined by the IOTN, demand—differences between urban and rural areas. Community
Dental Health 15: 272–276
but orthodontic intervention in the cases described
Bishara S E, Justus R, Graber T M 1998 Proceedings of the
above was initiated too late. Bäßler-Zeltmann et al. workshop discussions on early treatment. American Journal of
(1998) found an urgent treatment need in 32 per cent of Orthodontics and Dentofacial Orthopedics 113: 5–6
9-year-old children. Breistein B, Burden D J 1998 Equity and orthodontic treatment:
With reference to the validity of the IOTN in different a study among adolescents in Northern Ireland. American Journal
of Orthodontics and Dentofacial Orthopedics 113: 408–413
dentition periods, Johnson et al. (2000) suggested that
symptoms in the mixed dentition might be slightly Brook P H, Shaw W C 1989 The development of an index for
orthodontic treatment priority. European Journal of Orthodontics
overestimated between the ages of 10 and 13 years. 11: 309–332
Nevertheless, this minor discrepancy is no reason to Burden D J, Holmes A 1994 The need for orthodontic treatment in
delay the start of treatment. If symptoms such as overjet, the child population of the United Kingdom. European Journal of
overbite and crowding are excluded, the estimated treat- Orthodontics 16: 395–399
ment need in children aged between 6 and 8 years is Chi J, Harkness M, Crowther P 2000 A longitudinal study of
orthodontic treatment need in Dunedin schoolchildren. New
about 25 per cent.
Zealand Dental Journal 96: 4–9
A previous study demonstrated that, for the estimation
Crowther P, Harkness M, Herbison P 1997 Orthodontic treatment
of treatment need, the DHC gave more stable age- need in 10-year-old Dunedin schoolchildren. New Zealand Dental
related results than the SCAN (Tarvit and Freer, 1998). Journal 93: 72–78
Enlow D H 1966 A morphogenetic analysis of facial growth.
American Journal of Orthodontics 52: 283–299
Conclusions Evans R, Shaw W C 1987 Preliminary evaluation of an illustrated
scale for rating dental attractiveness. European Journal of
1. Between the ages of 6 and 8 years the prevalence of Orthodontics 9: 314–318
malocclusions is similar to that in adults, but the Firestone A R, Häsler R U, Ingervall B 1993 Treatment results
distribution of specific symptoms is different. in dental school orthodontic patients in 1983 and 1993. Angle
2. Deep overbite and increased overjet show the Orthodontist 69: 19–26
highest frequency, but there is a decline in line with Foster T D 1980 Orthodontic surveys—a critical appraisal. British
growth and development. Journal of Orthodontics 7: 59–63
3. The IOTN data give support for early treatment Ghabrial E, Wiltshire W A, Zietsman S T, Viljoen E 1998 The
epidemiology of malocclusion in Zambian urban school children.
need. Reverse overjet, crossbite and severe cases of South African Dental Journal 53: 405–408
overbite and overjet should be treated at an early Gianelly A A 2002 Treatment of crowding in the mixed dentition.
stage. These priorities conform with the hierarchical American Journal of Orthodontics and Dentofacial Orthopedics
system of the IOTN. 121: 569–571
Harzer W, Viergutz G, Hetzer G 1998 Zur Prognose traumatisierter
Schneidezähne mit unvollständigem Wurzelwachstum unter
Address for correspondence besonderer Berücksichtigung kieferorthopädischer Therapieplanung.
Stomatologie 95: 333–339
Professor Winfried Harzer Ingelsson-Dahlstrom M, Hagberg C 1994 The longitudinal
Poliklinik für Kieferorthopädie development of malocclusion in postnormal children with little
Universitätsklinikum, TU Dresden respectively urgent need for orthodontic treatment. Swedish
Dental Journal 18: 49–57
Fetscherstr. 74
Johnson M, Harkness M, Crowther P, Herbison P 2000 A com-
D-01307 Dresden parison of two methods of assessing orthodontic treatment need
Germany in the mixed dentition: DAI and IOTN. Australian Orthodontic
Journal 16: 82–87
Kerosuo H 1990 Occlusion in the primary and early mixed
Acknowledgement dentitions in a group of Tanzanian and Finnish children. ASDC
Journal of Dentistry for Children 57: 293–298
We are grateful for the financial support of the public
Kisely S, Howell K, Green J 1997 Pathways to orthodontic care.
health research project “Saxonian”. Journal of Public Health in Medicine 19: 148–155
Kluemperer G T, Beeman C S, Hicks E P 2000 Early orthodontic
treatment: what are the imperatives? Journal of the American
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