Maloklusi
Maloklusi
Maloklusi
Abstract
* Ph.D. and M.Sc. in Orthodontics, Rio de Janeiro Federal University (UFRJ). Adjunct Professor of Orthodontics, Federal University of Bahia (UFBA). Diplomate of the
Brazilian Board of Orthodontics and Facial Orthopedics.
** M.Sc. in Orthodontics, PUC/Minas. Ph.D. in Orthodontics, UNESP/Araraquara. Professor, Orthodontics Specialization Program, UFBA.
of the malocclusions present in Brazilian children distribution to all children. This action was geared
aged 6 to 10 years, and present two clinical situ- toward providing guidance to children and their
ations often associated with these malocclusions, parents/legal guardians about the proper way to
i.e., caries and premature loss of deciduous teeth. clean their teeth with instructions on brushing
and flossing, among others.
MATERIAL AND METHODS Data collection was performed under an arti-
This has been characterized as quantitative ficial light source with the child sitting in a chair
study, of a descriptive, exploratory and transversal and facing the examiner. Gloves, masks and dis-
nature. The sample was random and intentional: posable wooden spatulas were utilized.
4,776 Brazilian children aged between 6 and 10 Initially, an attempt was made to determine
years were evaluated without distinction of race whether or not the individual had a normal occlu-
or gender. None had received any previous orth- sion. If not, the examiners checked whether the
odontic treatment. Prior to data collection, the alteration was significant or whether there were
examiners fully explained to the children’s par- only small changes that would not jeopardize the
ents and/or legal guardians the purpose and im- establishment of an appropriate occlusal relation-
portance of the study, highlighting its many ben- ship in the future, both in terms of function and
efits. Moreover, they were instructed on practices aesthetics. Children with normal occlusion and
that can prevent or minimize future orthodontic those that had minor changes were categorized
problems in children. as favorable occlusion. In all others, the occlu-
Data collection was performed by clinical ex- sion was considered unfavorable and therefore the
amination and anamnesis as part of the campaign malocclusion features present in anteroposterior,
“Preventing is better than treating” conducted in transverse and vertical directions were identified.
18 Brazilian states and the Federal District involv- First permanent molar relationship was pref-
ing orthodontists affiliated with the Brazilian As- erentially observed, or else canine relationship,
sociation of Orthodontics and Facial Orthopedics on the right and left sides, to determine the type
(ABOR). The campaign was part of a 2009 Global of malocclusion according to Angle’s classifica-
Action Project implemented by the Social Service tion.4 The following groups were established:
for Industry (SESI) in partnership with Brazilian Class I, Class II division 1, Class II division 2 and
television network Rede Globo. ABOR—by means Class III.
of its 19 regional branches—provided nearly 300 The presence of crossbite was then observed
professionals, viz. member orthodontists or stu- in the anterior region, when one or more anterior
dents of Orthodontics Specialization programs rec- teeth were involved, or in the posterior region,
ognized by the Federal Council of Dentistry (CFO), when the crossbite involved teeth in this region.
who volunteered to participate. The evaluation In this case, it was subdivided into bilateral when
was conducted in the states of Amapá, Alagoas, present in the right and left sides, or unilateral
Bahia, Ceará, Espírito Santo, Goiás, Mato Grosso, when involving only one side.
Mato Grosso do Sul, Minas Gerais, Paraíba, Paraná, Regarding vertical changes, each child’s anteri-
Pernambuco, Piauí, Rio de Janeiro, Rio Grande do or overbite was evaluated. Considering that most
Norte, Rio Grande do Sul, Santa Catarina, São Pau- children would be in mixed dentition, a param-
lo, and in the Federal District. eter of 50% overbite was set as normal, i.e., an
A partnership was also forged with Colgate®, overlap of up to half the clinical crown of lower
which donated five thousand sets of tooth- incisors by the upper incisors. Any overlap greater
brush, toothpaste and explanatory leaflets for than 50% was categorized as deep overbite while
the absence of overbite was defined as open bite. As described initially the examiners sought to
If the child was in primary dentition the measure analyze whether the children had normal occlu-
of normality was an overbite of 10%, and if they sion. It was found that only 14.83% of the children
were in permanent dentition, 20% to 30%. fit this category while 85.17% had some kind of
The examiners also assessed the presence of altered occlusion, as can be seen in Figure 1.
clinically visible carious lesions and the loss of per- Subsequently, when reviewing occlusal charac-
manent teeth or premature loss of deciduous teeth. teristics in an attempt to determine whether the
Early loss was defined as loss due to tooth extrac- occlusion was favorable or not it was found that
tions motivated by diseases or injuries outside the aside from children with normal occlusion some
period considered as ideal for their exfoliation. minor changes were present in 16.77%, although
In the following step the examiners sought to these alterations would not jeopardize the estab-
determine whether the child required orthodon- lishment of an appropriate occlusal relationship.
tic care through either prevention or interception. Thus, the total number of children with favorable
Preventive orthodontic care was defined as guid- occlusion was 31.6% (Fig 2).
ance on the need for proper hygiene and occlusal In children who had no occlusal characteristics
development, space supervision and guidance on supportive of establishing an adequate future re-
abnormal pressure habits and on proper breathing lationship the malocclusion was examined in the
pattern. Interceptive care was defined as the need anteroposterior, transverse and vertical directions.
for space maintainers or regainers, serial extrac- The results are depicted in Figures 3 to 5.
tions and orthodontic mechanics for the correc- As can be seen in Figure 6, the presence of car-
tion of crossbites and open bites, and orthopedic ies and/or tooth loss was observed in most of the
procedures for the correction of Class II or III children (52.97%).
malocclusions. As stated above, the examiners sought to de-
termine whether each child required orthodontic
rESuLtS care, be it preventive or interceptive. The former
Regarding gender, 2,270 (47.53%) of the 4,776 was required by 72.34%, and the latter, by 60.86%
children were males and 2,506 (52.47%) females. of the children (Figs 7 and 8).
5000 4000
4000
3000
3000
2000
2000
1000
1000
0
0 Favorable Occlusion
Normal occlusion (708 = 14.83%) Yes (1,509 = 31.60%)
Malocclusion (4,068 = 85.17%) No (3,267 = 68.40%)
FIGURE 1 - Distribution of normal occlusion and malocclusion in children FIGURE 2 - Distribution of occlusions, in the examined children, that
of the sample. seemed favorable and unfavorable to the establishment of an appropri-
ate occlusal relationship in the future.
500
2000
400
1500
300
1000
200
500 100
0 0
Malocclusion Crossbite
Class I (1,939 = 40.60%)
Class II, 1 (879 = 18.40%) Anterior (497 = 10.41%)
Class II, 2 (153 = 3.20%) Unilateral posterior (308 = 6.45%)
Class III (296 = 6.20%) Bilateral posterior (130 = 2.72%)
FIGURE 3 - Distribution of malocclusion type according to Angle’s clas- FIGURE 4 - Distribution of the presence of crossbite in children with un-
sification in children with unfavorable occlusion. favorable occlusion.
2000 3000
2500
1500
2000
1000
1500
500 1000
500
0
Overbite
0
Normal (1,646 = 34.46%) Caries/Tooth Loss
Deep Bite (864 = 18.09%) Yes (2,530 = 52.97%)
Open Bite (757 = 15.85%) No (2,246 = 47.03%)
FIGURE 5 - Distribution of the presence of crossbite in children with unfa- FIGURE 6 - Distribution of tooth decay and/or loss in the children of the
vorable occlusion. sample.
3000
1200
2500
1000
2000 800
1500 600
400
1000
200
500 0
Interceptive Intervention
0
Preventive Intervention
Space Maintainance (644 = 13.48%)
Guidance (2,657 = 55.63%) Recovery/Space Control (1,136 = 23.79%)
Supervision (407 = 8.52%) Crossbite (441 = 9.23%)
Habits (263 = 5.51%) Open Bite (277 = 5.80%)
Breathing (128 = 2.68%) Orthopedics (409 = 8.56%)
FIGURE 7 - Distribution of the type of preventive care that should be FIGURE 8 - Distribution of the type of interceptive care that should be
given to children involving guidance, space supervision and approach- delivered, involving the need for space maintenance, space recovery
es related to abnormal pressure habits and mouth breathing. and/or control, crossbite and open bite correction, and orthopedic inter-
vention for correction of Angle Class II or Class III malocclusion.
ditions involving lesions caused by extensive (mouth breathing) was observed in 2.68% of the
tooth decay, and premature loss of primary total sample. Given that the literature establishes
teeth. Brazilian children have one of the highest an unequivocal link between malocclusion and
rates of premature extractions with no mainte- improper function of oral muscles,2,23,29,30 provid-
nance of the remaining space, and their lead- ing guidance to the children and/or their legal
ing cause of premature loss is tooth decay.10,12 It guardians was considered an essential preventive
has long been common knowledge that this is a procedure to decrease the probability of future
factor often associated with malocclusions,13,24 occlusal changes related to these problems in
since primary teeth should be kept healthy to 8.19% of the children.
provide support and preserve the integrity of As depicted in Figure 8, tooth loss had oc-
the dental arch, thereby allowing the eruption curred in 13.48% of the children, which required
of the succeeding permanent teeth.6 Untimely interceptive orthodontic intervention in order to
loss, depending on the region, occlusal rela- maintain the remaining space until the eruption
tionship, individual skeletal features and peri- of the permanent successors. Moreover, 23.79%
odontal conditions may cause overeruption of of the children already displayed problems re-
antagonist teeth.22 In this research, as shown lated to a slight lack of space, either by migration
in Figure 6, it was found that tooth decay and/ of adjacent teeth to a region of early loss, or by a
or loss were present in 52.97% of the children. transient negative difference between the volume
This result is much higher than that reported by of deciduous and permanent teeth. In both cases,
Ribas et al,22 who found a prevalence of 16.58% orthodontic appliances are indicated to minimize
of decay and/or premature loss in children be- or correct these alterations, and space regainers
tween 6 and 8 years of age in Curitiba (PR). could be used in the former case, as well as ap-
The premature loss of deciduous teeth or pliances which enable the use of leeway space,
the loss of permanent teeth with no immediate especially at the time of exfoliation of the second
replacement are potential causes of malocclu- primary molars.
sion.2,11 Thus, loss avoidance can help to prevent Although obvious, it should be stressed that
orthodontic problems and ensure normal devel- only qualified professionals should be allowed to
opment of the dentition and occlusion. In this re- handle this stage since it is an extremely impor-
gard, as shown in Figure 7, this study showed that tant phase in ensuring normal dentition develop-
appropriate guidance—not only on the need for ment and establishing an appropriate occlusal
proper cleaning or restoration of compromised relationship. In this sense, it is of paramount im-
teeth—but also on the development of denti- portance to distinguish patients who will ben-
tion, when provided by a qualified professional, efit from interceptive treatment from those for
had a positive impact on 55.63% of the children. whom corrective treatment is essential. Thus, it
Furthermore, 8.52% of the children exhibited an was determined that 441 (47.17%) of 935 chil-
altered sequence when replacing primary by per- dren with crossbite could benefit from inter-
manent teeth and therefore required professional ceptive treatment. This represents 9.23% of all
monitoring (space supervision) with the purpose children examined in this study. Likewise, 277
of attaining a more favorable sequence of eruption (36.59%) of the 757 children who had open bite
of permanent teeth from a physiological stand- would have to be treated at this stage, i.e., 5.8%
point. Abnormal pressure habits were observed of the total. Additionally, 409 (30.80%) of the
in 5.51% of the children and, although difficult to 1,328 children who had Angle Class II or Class III
assess clinically, an abnormal respiration pattern malocclusion also had skeletal disharmonies that
could be properly corrected at this stage, which policies should be grounded in knowledge about
translated into functional and aesthetic benefits the needs of the population, by correlating causes,
to 8.56% of the children. effects and solutions to the problems. With all
Given some difficulties in implementing a the data presented here the authors hope to con-
more specific and more detailed standardization, tribute to such planning by allowing the neces-
this study sought to provide only an overview sary material and human resources to be properly
of the occlusal situation of Brazilian children. estimated. Regarding the latter, and taking into
However, with its participation in the project, account the work published by Michael et al,14
ABOR has promoted an innovative activity, of which found that only 10.1% of undergraduate
great importance for public oral health services students from ten dental schools in the state of
as the target audience comprised needy children Rio de Janeiro could identify the characteristics
aged between 6 and 10 years, who had no access of normal occlusal development, ABOR is aware
to orthodontic guidance and assistance. It was of the fact that measures undertaken at this level
felt that the lack of guidance and public policies require professionals to demonstrate their ability
aimed at this segment of the population are the to perform diagnosis and an accurate treatment
key contributing factors to many of the occlusal based on a solid training provided by a course
problems encountered, especially those related that meets the requirements recommended by
to caries and/or tooth loss. ABOR in Brazil, and by the World Federation of
Needless to say, the planning of public health Orthodontists (WFO), in the international arena.
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Contact address
Marcos Alan Vieira Bittencourt
Av. Araújo Pinho, 62, 7º Andar, Canela
CEP: 40.110-150 – Salvador / BA, Brazil
E-mail: alan_orto@yahoo.com.br