Journal of Oral Biology and Craniofacial Research 14 (2024) 112–115

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Journal of Oral Biology and Craniofacial Research

journal homepage: www.elsevier.com/locate/jobcr

Malocclusion among children in Vietnam: Prevalence and associations with

different habits
Dung Anh Vu a, Hai Minh Vu b, *, Quyet Tri Nguyen a, Hoang Minh Vu a
a
Department of Odonto Stomatology, Thai Binh University of Medicine and Pharmacy, Thai Binh, 410000, Viet Nam
b
Department of Trauma, Thai Binh University of Medicine and Pharmacy, Thai Binh, 410000, Viet Nam

A R T I C L E I N F O A B S T R A C T

Keywords: Background: This study aimed to measure the prevalence of malocclusion and identify associated factors among
Malocclusion elementary school students in Vietnam.
Habits Method: A cross-sectional study was conducted from March to December 2022 at six primary schools located in
Student
the province of Thai Binh, Vietnam. A total of 873 students were recruited for research purposes. Students were
Children
Oral
classified into normal, malocclusion classes I, II and III. Bad habits were examined. Multivariate logistic
regression was used to detect associations.
Results: The prevalence of malocclusion was 60.7 %; 19.0 % had Class I, 31.0 % had Class II and 10.7 % had Class
III. Having finger sucking habit was associated with Class I malocclusion (OR: 3.28), and Class II malocclusion
(OR: 3.22). Having lip biting habit was related to a higher odds of having Class II malocclusion (OR = 4.37) Class
III malocclusion (OR = 6.83). Having tongue thrusting habit was associated with higher odds of having Class I
(OR: 5.25), and Class II malocclusion (OR: 6.42). Mouth breathing was related to a higher likelihood of having
Class II malocclusion (OR = 2.71). Having early loss of deciduous teeth was associated with a higher odds of
having Class III malocclusion (OR = 3.83).
Conclusion: Findings showed high prevalence of malocclusion, mostly class II, in elementary students in Vietnam.
Bad habits such as finger sucking, biting the lower lip, tongue thrusting, mouth breathing, and early loss of
deciduous teeth play important roles in developing malocclusion, which should be considered in the develop­
ment of interventions.

1. Introduction to patients seeking treatment in adulthood. As a result, treatment is

usually prolonged and challenging. The prompt advocates for early
Malocclusion, also known as an incorrect bite or dental malalign­ intervention in Class II malocclusion to minimize the degree of
ment, is the misalignment of the relationship between the teeth within misalignment, reduce the duration of orthodontic treatment, restrict the
one dental arch or between the upper and lower jaws. Malocclusion can need for tooth extraction, and minimize the necessity of surgical or­
have significant implications for the health of individuals, including thodontic intervention.1 There are several methods for treating Class II
joint dislocation, decreased chewing function, predisposition to the malocclusion, among which functional appliances are believed to
development of certain oral diseases, impacts on facial aesthetics, restore facial harmony by influencing the teeth and stimulating the
speech impediments, and psychological issues. Various causes can result development of the mandible in growing patients.
in malocclusion, such as early loss of deciduous teeth or poor oral habits. Understanding the prevalence of malocclusion is crucial in the
The timely detection and intervention to prevent malocclusion in chil­ development of suitable preventive and orthodontic intervention ini­
dren have not received adequate attention. A study examining the tiatives. Research studies have documented the prevalence of maloc­
prevalence of malocclusion in children and investigating the associated clusion in various populations,2–4 with significant variations even within
factors to propose effective, economical, and simple intervention the same population. These disparities may potentially arise from
methods is essential. Among the various types of occlusal malforma­ divergent factors such as ethnic backgrounds, sample sizes, data
tions, Type II malocclusion prevalence is relatively high and often leads collection techniques, or age distribution within the study cohorts.5 A

* Corresponding author.
E-mail address: vuminhhai777@gmail.com (H.M. Vu).

https://doi.org/10.1016/j.jobcr.2024.01.007
Received 6 November 2023; Received in revised form 8 January 2024; Accepted 13 January 2024
2212-4268/© 2024 Published by Elsevier B.V. on behalf of Craniofacial Research Foundation. This is an open access article under the CC BY-NC-ND license
(http://creativecommons.org/licenses/by-nc-nd/4.0/).
D.A. Vu et al. Journal of Oral Biology and Craniofacial Research 14 (2024) 112–115

study in Saudi Arabia showed that a Class I molar relationship in 1219 malocclusion involved the theoretical evaluation of clinical images and
participants, accounted for 61% of the 1998 school children. Addition­ a detailed discussion of each category, including the resolution of
ally, Class II and Class III molar relationships were observed in 326 possible disagreements. The training session was concluded upon
participants (16.3%) and 154 participants (7.7%).6 In China, 79.4% of reaching a satisfactory level of agreement and comprehension.
children have malocclusion, with Class II malocclusion accounting for The occlusal parameters documented by evaluators encompass
50.9 %.7 Another study in India showed that 49.7% of students had molar and canine interrelationships, overbite and overjet measure­
malocclusion.8 Recently, a systematic review synthesized 123 studies ments, anterior open bite assessment, spacing, and crowding analysis,
and revealed that the prevalence rates of Angle Class I, Class II, and Class identification of anterior crossbite, presence of a scissors bite, and
III malocclusion among healthy children and adolescents exhibited observation of posterior crossbite. Moreover, students were asked to
considerable variation, yielding mean prevalences of 51.9% (standard report their habits regarding finger sucking, lip biting, tongue thrusting,
deviation [SD] = 20.7), 23.8% (SD = 14.6), and 65% (SD = 6.5), mouth breathing, and early loss of deciduous teeth11,12 through obser­
respectively.9 vation and clinical examination. Information about nail biting and
In Vietnam, limited published data is currently accessible regarding thumb/finger sucking was gathered through a survey given to paren­
malocclusion. Only a prior study in 12- and 18-year-old students found ts/guardians, while the habit of lip/tongue interposition was assessed
that the prevalence rates of Angle Class I, Class II, and Class III maloc­ during a clinical examination conducted in both natural and artificial
clusion were 67%, 17.5%, and 15.5%, respectively.10 However, the light. Disposable tongue depressors were used to aid in the examination.
research has not addressed the role of students’ health behaviors in Malocclusion was observed in cases where there was a Class II or
malocclusion. Therefore, this study aimed to measure the prevalence of Class III molar relationship, or a Class I molar relationship accompanied
malocclusion and identify associated factors among elementary school by at least one of the following conditions according to Table 1.13
students in Vietnam. Providing this information plays a crucial role in
developing appropriate strategies for the advancement of oral care
2.3. Statistical analysis
services for children. Furthermore, this information also helps the school
to have evidence-based grounds to develop oral care plans for the
The data collected was subjected to analysis using Statistical Pack­
school, guiding and educating students on oral health communication,
ages for the Social Sciences (SPSS). The occurrence rate of malocclusion
and limiting inappropriate behavior that could affect the oral health of
was measured using proportions. The statistical analysis employed in
children.
this study involved the utilization of the Chi-square test to examine
disparities in proportion within the various groups. Multivariate logistic
2. Materials and methods
regression was used to identify associations between different habits of
students and malocclusion after adjusting to demographic characteris­
2.1. Study design and participants
tics. Significance levels were determined based on p-values less than
0.05, denoting statistical significance.
A cross-sectional study was conducted from March to December
2022 at six primary schools located in the province of Thai Binh, Viet­
nam. These schools were categorized as follows: two schools in urban 3. Results
areas, two schools in rural areas, and two schools in coastal regions.
Students aged 9–10 have been selected for the research study. The se­ Table 2 shows that among 873 students, most of them were male
lection criteria included: 1) currently enrolled in selected schools; 2) no (53.4%), aged 9 years old and living in urban areas (38.2%). The
prior orthodontic or maxillofacial corrective treatment; 3) no history of prevalence of malocclusion was 60.7%; 19.0% had Class I, 31.0% had
maxillofacial trauma or congenital deformities; and 4) having all per­ Class II and 10.7% had Class III.
manent first molars and intact teeth to determine the type of bite oc­ Table 3 shows that the rate of students having finger-sucking habits
clusion. The exclusion criteria consist of: 1) the presence of systemic was the highest among those with Class II (5.5%), and Class I (5.4%) (p
pathologies affecting craniofacial development and dental arch; and 2) < 0.03). The proportion of students having lip-biting habits was the
students or parents who did not consent to participate in the study or did highest in those with Class III (6.5%) (p < 0.01). The highest rates of
not cooperate during the research process. students having tongue thrusting and early loss of deciduous teeth were
The size of the sample is calculated using an estimated ratio formula in students with Class II (4.4%) and Class III (10.8%) (p < 0.05),
with relatively accurate precision, where α = 0.05, ε (relative accuracy) respectively. No difference was found among groups of malocclusion
= 0.085, and the expected malocclusion ratio in each elementary school according to mouth breathing habits.
is 79.4%.7 The required sample size for the study was 828. Furthermore, Table 4 illustrates the results of a multivariate regression analysis
an additional 10% sample size was included as a dropout prevention examining the impact of bad habits and early tooth loss on malocclusion.
measure, resulting in a total of 910 students being invited to participate Students with a finger-sucking habit were found to have 3.28 times
in the study, with data from 873 students being included in the research. higher odds of developing Class I malocclusion (OR: 3.28; 95 % CI:
To begin with, primary schools in Thái Bình province were classified 1.07–10.10; p < 0.05), and 3.22 times higher odds of developing Class II
into three regions: urban, rural, and coastal. Afterward, two elementary malocclusion (OR: 3.22; 95 % CI: 1.13–9.16; p < 0.05) compared to
schools were randomly selected in each region. At each primary school,
two classes were randomly selected from the 4th and 5th grades, and all Table 1
the students from these two classes were invited to participate in the Criteria for diagnosing malocclusion.
study. A total of 873 students were recruited for research purposes. The Criteria Normal Malocclusion
research has been approved by the Provincial People’s Committee of 1 Correlation with I I, II, III
Thai Binh (Decision No. 1302/QD-UBND dated June 3, 2021). R6
2 Crown angulation 2.79 ± 1.29 mm (1.5–4.08 <1.5 mm or > 4.08 mm
mm)
2.2. Data collection
3 Crown inclination 2.89 ± 1.45 mm (1.44–4.34 <1.44 mm or > 4.34
mm) mm
The data collection process involved clinical examinations per­ 4 Rotation None Yes
formed by two skilled general dental practitioners. The practitioners 5 Spaces None Yes
employed various tools, including gloves, a light source, a mouth mirror, 6 Flat occlusal None Yes
planes
and a calibrated ruler. The training and calibration process for

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D.A. Vu et al. Journal of Oral Biology and Craniofacial Research 14 (2024) 112–115

Table 2 with compromised dentofacial aesthetics, disruption of oral function­

Demographic characteristics of students. ality including mastication, swallowing, and speech, as well as an
Characteristics Freq. (n) Percent (%) increased vulnerability to trauma and periodontal disease.
In our study, it was observed that the rate of children with maloc­
Gender
Male 466 53.4 clusion accounted for 61.0 %. This finding exhibits a lower outcome
Female 407 46.6 compared to several international studies. Xin Yu’s (2019) studied on
Age the prevalence of malocclusion and characteristics of mixed dentition in
9 475 54.4 early Chinese children and the author observed that 79.4% of children
10 398 45.6
Living location
exhibited one or more malocclusion abnormalities.7 In a study con­
Urban 334 38.2 ducted on a sample of 503 preschool children, it was observed that
Rural 273 31.3 71.4% of the children displayed one or more malocclusion attributes,
Seaside 266 30.5 while 16.9% exhibited poor oral hygiene habits.14
Malocclusion
The major type of malocclusion in our study was Class II. Our study
Normal 343 39.3
Class I 166 19.0 differs from a previous study in Vietnam as it demonstrates the preva­
Class II 271 31.0 lence rates of Class I, Class II, and Class III malocclusion to be 67%,
Class III 93 10.7 17.5%, and 15.5%, respectively.10 The findings of the research align
with the work of Xin Yu et al. revealing that the prevalence of Class II
malocclusion exhibited the highest proportion at 50.9%, followed by
those without this habit. When students had the habit of biting their lips,
Class I malocclusion at 42.3 %, and Class III malocclusion at 5.9%.7
the odds ratio (OR) of developing a Class II malocclusion increased 4.37
However, results of this study were computed among students with a
times (OR = 4.37, 95%CI: 1.19–16.00; p < 005), and the odds ratio of
malocclusion rather than being computed collectively within the
developing a Class III malocclusion increased 6.83 times (OR = 6.83, 95
research sample size. A prior systematic review revealed that the
% CI: 1.64–28.42; p < 005). When students had tongue thrusting habit,
average prevalence of normal occlusion was found to be 46.3 ± 27.3%.
the odds ratio for Class I malocclusion increased by 5.25 times (OR: 5.25;
Specifically, the prevalence of malocclusion type I was estimated to be
95%CI: 1.03–26.71; p < 0.05), and the odds ratio for Class II maloc­
46.5 ± 17.0%, type II malocclusion was found to be 25.0 ± 13.2%, and
clusion increased by 6.42 times (OR: 6.42; 95%CI: 1.40–29.41; p <
type III malocclusion was reported to be 7.0 ± 7.9%.15 The findings of
0.05). When individuals had a habit of mouth breathing, the odds of
our study confirmed that malocclusion is one of the prevalent oral health
having Class II malocclusion increased by 2.71 times (OR = 2.71, 95%
issues among primary school students.
CI: 1.02–7.21, p < 0.05). For students having early loss of deciduous
There is a consensus among studies that malocclusion can be caused
teeth, the odds of having Class III malocclusion increased 3.83 times
by both genetic and environmental factors. The occurrence of poor oral
(OR = 3.83, 95%CI: 1.48–9.94 p < 0.05) compared to students who did
habits serves as a prominent illustration of how children’s habitual be­
not early lose their deciduous teeth.
haviours can influence the development of malocclusion.16,17 The most
common bad oral habits are finger-sucking, lip-biting, tongue-thrusting,
4. Discussion
and mouth-breathing over an extended period, which can result in un­
intended teeth movements and misalignment. In the age group of 8–10
Malocclusion represents a prevailing dental issue among individuals.
years, corresponding to the mixed dentition period, which is a sensitive
Maloccluded teeth have been linked to psychosocial issues associated

Table 3
Malocclusion according to different habits of students.
Characteristics Malocclusion p-value

No Class I Class II Class III

N % N % N % N %

Finger sucking Yes 5 1.5 9 5.4 15 5.5 4 4.3 0.03

No 338 98.5 157 94.6 256 94.5 89 95.7
Lip bitting Yes 3 0.9 3 1.8 11 4.1 6 6.5 <0.01
No 340 99.1 163 98.2 260 95.9 87 93.5
Tongue thrusting Yes 2 0.6 6 3.6 12 4.4 3 3.2 0.02
No 341 99.4 160 96.4 259 95.6 90 96.8
Mouth breathing Yes 6 1.7 8 4.8 15 5.5 4 4.3 0.08
No 337 98.3 158 95.2 256 94.5 89 95.7
Early loss of deciduous teeth Yes 9 2.6 8 4.8 13 4.8 10 10.8 0.01
No 334 97.4 158 95.2 258 95.2 83 89.2

Table 4
Multivariable logistic regressions in identifying associations between different habits and malocclusion.
Characteristics Malocclusion (ref = Normal)

Class I Class II Class III

OR 95%Confidence interval OR 95%Confidence interval OR 95%Confidence interval

Finger sucking (No vs. Yes) 3.28* 1.07–10.10 3.22* 1.13–9.16 2.16 0.54–8.68
Lip biting (No vs. Yes) 1.91 0.38–9.63 4.37* 1.19–16.00 6.83* 1.64–28.42
Tongue thrusting (No vs. Yes) 5.25* 1.03–26.71 6.42* 1.40–29.41 4.5 0.72–28.05
Mouth breathing (No vs. Yes) 2.42 0.81–7.19 2.71* 1.02–7.21 2.04 0.55–7.54
Early loss of deciduous teeth (No vs. Yes) 1.62 0.60–4.34 1.53 0.63–3.72 3.83* 1.48–9.94

These models were adjusted to age, gender, and living location.

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D.A. Vu et al. Journal of Oral Biology and Craniofacial Research 14 (2024) 112–115

transition phase from primary dentition to permanent dentition, the Funding statement
examination and detection of occlusal discrepancies and their causes are
of utmost importance (especially bad oral habits), to develop an None.
appropriate intervention plan that can yield the highest effectiveness.
The intervention of orthodontic correction during this phase is referred Conflict of interest disclosure
to as facial orthopaedics, which involves the implementation of several
straightforward treatment methods to prevent dental malocclusions. None.
Kristina Kasparaviciene (2014) found that lingual lip seal incompetence
accounted for 71.4% of cases, while children with one or more negative Ethics approval statement
habits affecting occlusion accounted for 16.9%.14 Multiple studies have
also suggested that mouth breathing has negative effects on the devel­ This study was approved by the Institutional Review Board of the
opment of the craniofacial complex.18,19 The findings of our study also Thai Binh University of Medicine and Pharmacy (Code: 1834/QD-
clearly demonstrate a correlation between bad habits and malocclusion YDTB).
status, consistent with prior research. We also investigated the correla­
tion between early loss of deciduous teeth and malocclusion. The pre­ Patient consent statement
mature loss of deciduous teeth, especially tooth number 5 in the upper
jaw, can cause misalignment of the adjacent teeth. Additionally, the first All participants and their parents were required to give written
permanent molar would move closer to the gap caused by the loss of informed consents.
deciduous tooth number 5. The early loss of deciduous tooth number 5 is
often the leading cause of Class II malocclusion, characterized by dental References
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Data availability statement

The data are available upon request.

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