Pattern, Prevalence and Severity of Malocclusion Among University Students

Pattern, Prevalence and Severity of Malocclusion Among University Students
Rozina Nasir1, Nasreen Amanat2, Kulsoom Fatima Rizvi3

1 Assistant Professor & HOD Orthodontic Bahria University Medical and Dental College
2 Principal (Dental Section) Professor & HOD Oral Maxillofacial Surgery Bahria University Medical and Dental College
3 Assistant Professor & HOD Community Dentistry Bahria University Medical and Dental College
Correspondence: Dr Rozina Nazir

How to CITE:

Nazir R, Amanat N, Rizvi KF. Pattern, Prevalance and Severity of Malocclusion Among University Students. J Pak Dent Assoc 2013;22(1):13-18.


To determine the pattern, prevalence & severity of malocclusion among university students.


A cross-sectional study was conducted among 521 University students, age ranged from 1724 years while mean age was 19.7 years (SD±1.8). Students were examined for malocclusion using Angle’s Classification and overjet, overbite, crossbite,anterior crowding, smile arc, generalized spacing & midline diastema. Statistical analysis was carried out using chi-square test. Descriptive statistics and Cross tabulations of Malocclusion Traits i.e. Crowding, spacing, overjet, overbite, crossbite, Smile arc and gender differences, with Angle’s Classes were also performed.


Angle’s Class I Malocclusion was most prevalent (41%). Anterior Crowding in 42% students was a major occlusal finding. Increased overjet was found in 30% of the population. No obvious gender difference was noted, except for increased overbite (more prevalent in boys, P<.001).


Majority of the university students had malocclusion. Class 1 malocclusion and anterior crowding were the most common finding.


Pattern, Prevalence, Severity, Malocclusion, Angle’s Classification


Malocclusion is defined as an occlusion in which there is an abnormal relationship, or there are
irregularities in tooth position beyond normal limits.1 Malocclusion has a great impact on both person and society in terms of quality of life, anxiety, and social and functional confines.2 A person with malocclusion may feel introverted in social circumstances, might develop a feeling of disgrace about their dental appearance and or lose career opportunities.3

The decision to start orthodontic treatment is influenced by self-perception of dental appearance, confidence, the

wish to look attractive, gender, age, and contemporary norms.4,5 The main advantage of orthodontic treatment is enhancement of physical function, improvement of esthetic components and avoidance of tissue damage.6 Numerous features can describe the position and occlusion of teeth, but it has always been difficult to make reliable assessments of dentofacial characteristics, the main difficulties being the definition of criteria and standardization of examiners.7 Methods of recording and measuring malocclusion can be broadly divided into two types i.e. qualitative and quantitative.8 While the severity or the extent to which a malocclusion deviates from the normal or ideal occlusion can be quantified by using number of varaibles,9 among the qualitative methods of recording malocclusion, Angle’s method of classifying malocclusion with or without modifications is probably the most widely used method. Angle’s classification of malocclusion in 1899 was a significant step in the progression of orthodontics.10 It not only subdivided the main types of malocclusion, but also presented the first patent definition of normal occlusion. Ever since, several indices and classifications have been developed but as so far none has been unanimously accepted. This could be due to differences in the terminology, sampling differences of gender and age, height of severity and the accuracy of examining techniques. Moyers11 considered it the most useful and well known method of studying occlusion, and Graber and Vanarsdall12 also confirmed the practicality and ease of this system. Quantitative means of calculating and recording occlusal characteristics are essential for epidemiologists and for those forecasting the condition of orthodontic services in a certain community. Genetic, environmental or a combination of both factors, along with a variety of local factors such as bad oral habits and abnormality in number, form, and developmental location of teeth, can lead to malocclusion.13 Malocclusion increases the incidence of dental caries, also affects periodontal health, and causes temporomandibular joint disturbances and severe psychological problems.1Therefore, it is essential to determine the incidence of malocclusion and its happening and distribution in a community.

In current years, there has been a steady rise in the quantity of adolescent and adult patients looking for orthodontic treatment in the dental colleges and other community or private dental centers. The occurrence of busy dental clinic and long waiting lists is a sign of the disparity between the increasing demand for orthodontic treatment and the deficiency of funds needed to offer high quality oral health services in Pakistan.Very few studies have assessed the pattern, prevalence and severity of malocclusion in Pakistan. This study aimed to offer orodental health care planners with update on, the incidence of individual characters of malocclusion, including anteriorposterior relationship, overbite, open bite, overjet, anterior and posterior crossbite, irregularity score for upper and lower anteriors, midline diastema, smile arc and the gender distribution of occlusal difference and whether a major difference be present among the population examined. Study of the frequency of occlusal characters in remote human populations can give important information regarding the etiology of malocclusions and other complex traits. The documents will be useful to provide a quantitative information on pattern of malocclusion among Pakistani population which is important for planning community orthodontic and dental services, and to aid further studies on etiology, environmental and genetic interactions and their effect on malocclusion.


This cross sectional study was conducted at BahriaUniversity in october 2011. The sample consisted of 521 students from Bahria University (263 boys and 258 girls)belonging to different areas of Pakistan. The students were provided with information on the study protocol and informed concent was taken. The criteria for selection was: No previous history of orthodontic treatment, Age between 17-24 years, no history of disease, trauma or surgical procedure that could influence occlusion, permanent dentition present with no retained deciduous teeth and no multiple missing teeth. Oral examinations were performed by two trained examiners in Dental OPD. Examination was carried out while the patient was sitting in a dental chair by using dental mirror, probe and a ruler.

Clinical examination of each participant was done and the occlusal relationship was recorded in centric occlusion as described by Parker.14 Angle’s Classification was used to describe the anteroposterior relationship of maxillary and mandibular first molars during maximum intercuspation, it was recorded as Normal occlusion,Class I, Class II and Class III malocclusion.10 Overjet ( 1-2mm normal, >3mm increased,<1mm decreased, edge to edge, negative) ,overbite (0-2mm normal, >2mm deep, open bite) anterior crowding ( 1-3mm mild, 4-6mm moderate, >6mm severe), anterior cross bite, posterior crossbite(bilateral, right and left) midline diastema (space > 1 mm between the central incisors) and pattern of Smile arc (consonant, nonconsonat or flat and reverse) were recorded. For Smile Arc Analysis full frontal smile photograph of every student was taken and evaluated. The software used for data analysis was SPSS version 15. Descriptive statistics were calculated to find the means and standard deviations. Data collected were pooled to determine frequencies, and cross tabulations of malocclusion traits with Angle’s classification were evaluated using chi-square test. Smile arc was crosstabulated with overbite.


Out of 521 Students, 263(50.5%) were boys and 258(49.5%) were girls. Age range was 17 – 24 years with mean age of 19.7 years (SD±1.8). The distribution of malocclusion is presented in Fig 1. Angles Class I malocclusion was most prevalent (41%). 30% of the population had increase overjet, mostly present in Class II malocclusion group. 28% had deep bite and 5.4% have anterior open bite. Anterior crossbite was present in 3.1% individuals and was present mostly in Class III malocclusion. Posterior cross bite was registered in 7.3%, generalized spacing was found in 6.7%, while midline

Fig. No. 1 Frequency and Distribution of sample by Angle’s Classification

Table: 1 Frequemcy of Distribution of Different Traits of Malocclusion in Relation to Angle’s Classes

diastema was found in 6.9% ( shown in Table 1). Anterior Crowding found in 42% students was a major occlusal finding and was mostly found in Class I and II malocclusion groups as shown in Table 2. Pattern of Smile arc distribution shows that Flat Smile arc was present in 31.7% and Reverse Smile arc in 8.8% which frequently occured in anterior open bite groups as shown in Table 3.

Table:2 Frequemcy of Anterior Crowding in Relation to Angle’s Classes

Table:3 Pattern of Smile Arc Distribution

No obvious gender difference was noted, except for an increased overbite which was most prevalent in boys. (P<.001).


Many studies, although, have been published describing the frequency and types of malocclusion, it is hard to evulate, contrast and compare these findings; partially, due to different methods and indices used to evaluate the occlusal findings, specific objectives, examiner subjectivity, age variations of study populations and different sample sizes.15 The technique used in this study was taken from different studies. 16,17,18 Malocclusion was found in 79% of our sample. This rate was almost same as reported by Afzal et al19 and higher than reported by Guray et al20 and Ugur et al.21 Ugur et al21 and Proffit et al22 have reported that with increase in age of patients orthodontic treatment needs increases, age range of this study was higher as compared to other studies.

Angle’s Class I was most frequent in our study population(41%)as compared to Class II (31%) and its almost same as reported by Afzal et al.20 On the contrary Ijaz A,23 Hameed et al24 & Erum reported Angle’s Class II as the most common pattern of malocclusion. This variation correlates with the fact that different population group was chosen in our study. In this study and studies by Shehzad et al26 and Afzal et al19, data was collected from Dental OPD as opposed to orthodontic OPD in other studies.27 In North American Caucasian children, Massler28 studied 2758 children and also found Class I to be most frequent. In a study by Silva and Kang,15Latin adolescents confirmed increased frequency of Class I malocclusion (69.4%). Onyeaso18described that Class I malocclusion was more frequent in Nigerian adolescents (50%)Lauc29 described that Class II malocclusion was more frequent in their population (45.1%), and described this number by a genetic influence on the prevalence of Class II malocclusion. The prevalence of Class III malocclusion (7.68%) determined in this study is almost same as Khan et. al.27 On the contrary, lesser rates were reported by Erum25, Silva and Kang15 and Onyeaso.18 However Haynes30 (2.5%), Proffit et al22 (5.7%) and Thilander et al16(5.8%) reported even lower rates. The current study confirmed that the predominant sagittal relationship of our population is Angle’s Class I.

We found high percentage of increased overjet (30%) and overbite(27.8%) in this study was mostly associated with Class II malocclusion group.Our findings agree with those of Erum et. al.25 in Pakistan, Thilander et al16 in Bogotanian adolescents and Ciuffolo et al17 in Italian adolescents who reported higher rate of increased overjet. In a Nigerian population, Onyeaso18 reported that increased overjet was not as large as it was in white people.

Among vertical anomalies, deep bite was more than four times(28%)as frequent as anterior open bite(5.4%). Our results were comparable to the rates reported by others16,25,29as deep bite was frequently related with a Class II malocclusion and more frequent in boys. The studies by Nganga et al31 and Garcia et al32 showed a higher prevalence of anterior open bite. These disparities could be due to difference in development and growth of the arches, or due to different harmful oral habits, tongue thrusting, mouth breathing, or dental and alveolar anomalies of the jaws. There was no statistically significant differences in any of the above citied studies between boys and girls.

Crowding in the anterior segment was the most common of all anomalies recorded (41%). This finding complied with the results of others.16,25,29Yet, other studies have reported lesser rates of anterior crowding.18,30 Nutrition Survey III by National Health was carried out in the USA between 1989 and 1994 explained the incidence of crowding ranging from 42.3% at ages 8–11 to 54.5% at ages 12–17 which was almost equal to the frequencies observed in this investigation.

Anterior crossbite was present in 3.1% while unilateral & bilateral posterior crossbite was 7.3%. Among unilateral posterior cross bite right side was effected more. This rate was comparable to the findings of Thilander et al16 and was less than Ciuffolo et al.17

Thilander et al16 found the incidence of 4% median diastema in their population in the permanent dentition. Lauc29 observed an elevated rate of midline diastema (45.1%). The incidence of diastema in Nigeria was 24%. Onyeaso18 pointed out that diastema is not considered as a malocclusion amongst Nigerians but as a symbol of natural beauty.In contrast this study showed median diastema of 6.9% & generalized spacing of 6.7%. Consonant smile arcs are present in both genders but more
in girls and flat & reverse smile arcs were more common in boys. This study shows that flat and reverse smile arc is mostly present in cases with anterior open bite. This demands that we rethink some of our orthodontic mechanics and concepts of treatment to consistently build this factor into our diagnostics, treatment planning, and treatment regimens.Orthodontic history, beginning with Angle and Wuerpel, has taught us that the “art of the smile” lies in the clinician’s ability to identify the essentials of beauty in every patient to create a plan to augment the characteristics and identify the limitations. Advance technologies basically improve our ability to see patients more with passion and make possible the emergence of newer ideas of function and esthetics.

It is clear that numerous genetic and environmentalinteracting features are associated with the etiology of malocclusions. Specific factors like muscle dysfunction, skeletal and dental growth disturbances, disorders in embryologic and orodental development, soft diet, tongue trusting, mouth breathing, sucking, and other habits as well relate with heridity in the progression of major types of malocclusion.The complexity in unraveling these factors is obvious in terms of gene–environment interactions, intraoral ecological change is a critical factor but this change may also disclose formerly masked genetic effects.

Well educated, trained and experienced specialists can develop indices appropriate for the local needs, work together in teams, develop the educational quality and facilities in dental schools and private clinics, and encourage epidemiological research projects. In this study number of variables are used while evaluating patterns of malocclusion which mostly were not used in local studies.
Due to the difference in racial and ethnic background, differences in malocclusion characteristics between Pakistan and other countries is expected.


Our findings suggest that almost 79% of young adults have malocclusion, while Angle’s Class I malocclusion (41%) as most prevalent malocclusion trait. Anterior crowding (42%) was a major occlusal finding.


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