Occlusal traits and orthodontic treatment need in 7- to 10-year-olds in Estonia

ORIGINAL ARTICLE Occlusal ai s and o hodon ic ea men need in 7‐ o 10‐yea ‐olds in Es onia He el Sepp 1 |Ma e Saag 1 |Anna‐Liisa S eds öm‐O is o 2 |Timo Pel omäki 3 | Heli Vinkka‐Puhakka 2 1 Depa men o S oma ology, Uni e si y o Ta u, Es onia 2 Depa men o O al De elopmen and O hodon ics, Ins i u e o Den is y, Uni e si y o Tu ku, Finland 3 Facul y o Medicine and Li e Sciences, Uni e si y o Tampe e, Finland Co espondence He el Sepp, Depa men o S oma ology, Uni e si y o Ta u, Raekoja pl. 6, EE51003 Ta u, Es onia. Email: [email p o ec ed] Abs ac The aim o his s udy was o e alua e he dis ibu ion o occlusal ai s and o hodon ic ea men need and complexi y in Es onian 7‐ o 10‐yea ‐old child en. This da a p o ides solid in o ma ion o planning o o hodon ic ca e. Da a o 392 Es onian child en (198 gi ls and 194 boys, mean age 9.0 yea s, ange 7.1–10.4 yea s) was analysed in his c oss‐sec ional s udy. Assessed ai s included i s mola and canine sagi al ela ionship, o e je , o e bi e, c owding, midline dias ema, c ossbi e, and scisso bi e. O hodon ic ea men need and complexi y we e assessed using he Index o Complexi y, Ou come, and Need. Pa en s' opinion ega ding hei child's ee h was de e mined using a ques ionnai e. The mos p e alen occlusal ai s we e canine class I sagi al ela ionship (73.7%), midline dias ema (73.0%), mola class I sagi al ela ionship (57.4%), and o e bi e ≥3.5 mm (51.8%). Acco ding o he Index o Complexi y, Ou come, and Need, 64.3% o Es onian elemen a y school child en we e in need o o hodon ic ea men . T ea men complexi y was simple in 12.5%, mild in 38.8%, mode a e in 22.7%, di icul in 14.0%, and e y di icul in 12.0% o he child en. App oxima ely 66.4% o he pa en s el ha hei child needed o hodon ic ea men . This s udy con i ms ea lie indings indica ing ha he mos equen sagi al ela ionship is class I in he i s mola s and class I in he canines. Howe e , he sagi al ela ionship was asymme ic in mo e han hal o he child en. Co ela ion be ween objec i ely de ined ea men need and pa en s' desi e o ea men was high in Es onia. KEYWORDS den al occlusion, ICON, ea men need 1|INTRODUCTION O hodon ic ea men has been ound o imp o e o al heal h‐ ela ed quali y o li e (Sil ola, Rusanen, Tol anen, Pi iniemi, & Lah i, 2012), and demand o o hodon ic ea men is g owing in many coun ies. Inc eased a en ion is paid o acial and den al appea ance, which ha e been ound o a ec , o example, social ela ionships, sel ‐es eem, and conclusions o he s make on he basis o ex e nal cha ac e is ics (Ke osuo, Hausen, Laine, & Shaw, 1995; Nisbe & Wilson, 1977; Ri e , Casey, & Langlois, 1991). The e a e also a e associa ions be ween den al ea u es and unc ions dis an o he o al ca i y (Giuca, Capu o, Nas asio, & Pasini, 2011; Hul c an z & Lö s and‐Tides öm, 2009; Miles, Vig, Weyan , Fo es , & Rocke e, 1996; Monaco e al., 2011; Schü z‐F ansson & Ku ol, 2008). In publically unded o hodon ic ca e, da a on occlusal ai s among 7‐ o 10‐yea ‐olds a e essen ial o planning o ea men s a egies. Ea ly mixed den i ion s age p o ides a good ime poin o conside in e cep i e o hodon ics (Ke osuo, Väkipa a, Nys öm, & Heikinheimo, 2008; Sunnak, Johal, & Fleming, 2015). In he oldes child en o his age g oup, clinical signs o skele al and den al de ia ions a e o en clea ly isible enabling he u he planning o , o example, wo k o ce and di ision o wo k. Planning o popula ion‐based, cos ‐e ec i e heal h se ices should be ounded on da a ocusing on he a ge coun y. Because ------- ------------ ------------ --------- ------------ ------------ ---------- ------------ ---------- ------------ ------------ -------- This is an open access a icle unde he e ms o he C ea i e Commons A ibu ion License, which pe mi s use, dis ibu ion and ep oduc ion in any medium, p o ided he o iginal wo k is p ope ly ci ed. ©2017 The Au ho s. Clinical and Expe imen al Den al Resea ch published by John Wiley & Sons L d. Recei ed: 18 Janua y 2017 Re ised: 24 Feb ua y 2017 Accep ed: 3 Ma ch 2017 DOI: 10.1002/c e2.64 Clin Exp Den Res. 2017;3:93–99. wileyonlinelib a y.com/jou nal/c e2 93 no da a exis on he p e alence o occlusal ai s and o hodon ic ea men need in Es onia, his s udy is he i s in a se ies o ex ensi e in es iga ions analysing he p e alence o occlusal ai s in child en and adolescen s om 3 o 21 yea s o age. Pa en s' and adolescen s' expec a ions and pe cep ions conce ning o hodon ic ea men a e also e alua ed. The aims o his s udy we e • o e alua e he dis ibu ion o occlusal ai s in 7‐ o 10‐yea ‐old child en in Es onia and • o e alua e he objec i e and subjec i e need o o hodon ic ea men in Es onia. 2|METHODS 2.1 |Subjec s Rec ui men o 7‐ o 10‐yea ‐old child en s a ed in No embe 2009 and was comple ed in Decembe 2010. A mul is age s a i ied clus e sampling design was implemen ed. The ec ui men ook place in ou andomly selec ed elemen a y schools: one in Tallinn (No he n Es onia), wo in Ta u (Sou h Es onia), and one in Pä nu (Sou h‐Wes Es onia). All he second‐g ade child en in selec ed schools we e in i ed o pa icipa e in he s udy. Sample size was de e mined wi h he aid o a s a is ical powe calcula ion. The selec ion o child en is illus a ed in Figu e 1. The inal sample consis ed o 392 child en (198 gi ls and 194 boys, mean age 9.0 yea s, age ange 7.1–10.4 yea s). P io o he s udy, a w i en desc ip ion o he s udy p o ocol was gi en o all child en and hei pa en s o gua dians. All pa icipan s signed an in o med consen o m, indica ing ha hei pa icipa ion in he s udy was olun a y. The s udy p o ocol was app o ed by he E hics Re iew Commi ee on Human Resea ch o he Uni e si y o Ta u (P o o- col No. 186T‐24). 2.2 |Clinical examina ion Fi e occlusal ai s we e egis e ed clinically in cen ic occlusion, sepa a ely o he le and igh sides: (a) sagi al ela ionships o he i s mola s and canines, (b) o e je , (c) o e bi e, (d) c ossbi e, and (e) scisso bi e. All clinical examina ions we e pe o med by Examine 1. The examina ion was ca - ied ou in he school's den al o ice using a den al mi o , p obe, pencil (0.3 mm), and millime e ule (Den au um 042‐751 Münchne Modell). Algina e imp essions o plas e cas s we e aken om each child. 2.3 |Plas e cas s Examine s 1 and 2 egis e ed h ee ea u es om he plas e cas s in o de o achie e consensus: (a) end‐ o‐end ela ionship o he i s mola s and deciduous and pe manen canines sepa a ely o he igh and le side, (b) c owding, and (c) dias emas be ween cen al inciso s. Regis a ion o he occlusal ai s was based on in e na ional s anda ds (B unelle, Bha , & Lip on, 1996; Ho owi z & Hixon, 1966; Moo ees, 1959); a de ailed desc ip ion o de ini ions is gi en in Appendix A. Fu - he mo e, using he plas e cas s, Index o Complexi y, Ou come, and Need (ICON) o o hodon ic ea men was assessed acco ding o w i en ins uc ions (Daniels & Richmond, 2000) by Examine 1. 2.4 |Reliabili y Be o e he in ended s udy a e 1 week, Examine 1 e‐examined clinically 22 child en. To assu e he alidi y o ICON assessmen s, 39 andomly selec ed plas e cas s (10%) we e analysed by bo h Examine 1 and by an ICON calib a ed Examine 3. FIGURE 1 Selec ion o he inal s udy sample 94 SEPP ET AL. The in aexamine eliabili y was good ( > .97). The in e examine eliabili y a ied om mode a e ( = .50) o good ( > .93). 2.5 |Ques ionnai e The gua dians' opinions ega ding a child's gene al den al heal h, oo h alignmen , den al appea ance, and opinion ega ding o hodon ic ea men need we e ga he ed h ough i e ques ions (Appendix B). The ques ionnai e was illed ou a home by one o he pa en s. Mo e han one answe pe ques ion was allowed. Ques ions we e modi ied o his s udy om simila ques ions in a p e ious s udy (Pie ilä & Pie ilä, 1996). 2.6 |S a is ical analysis The es – e es (Pea son's and Spea man's co ela ions) and chi‐squa e es we e used o compa e he equencies o speci ic ea u es (IBM SPSS .20 so wa e o Windows). p alues o less han .05 we e conside ed s a is ically signi ican . 3|RESULTS 3.1 |Occlusal ai s among 7‐ o 10‐yea ‐old Es onian child en The mos p e alen occlusal ai s in Es onian 7‐ o 10‐yea ‐old child en we e class I canine ela ionship (73.7%), midline dias ema (73.0%), class I mola ela ionship (57.4%), and inc eased (≥3.5 mm) o e bi e (51.8%). The sagi al ela ionship in canines and mola s was asymme ic in a la ge numbe o child en (33.2% and 35.7%, espec i ely). The de ailed p e alence o occlusal ai s is p esen ed in Table 1. The e we e only 17 child en (4.3%, 9 gi ls and 8 boys) wi h symme ical class I canine and mola ela ionships, o e je and o e bi e o 1–3 mm, wi hou c owding, scisso bi e, c ossbi e, and nega i e o e bi e. The o e je anged om −1 o 10 mm (mean 3.1 mm, SD 1.67). The o e bi e anged om −2 o 8.5 mm (mean 3.2 mm, SD 1.75). C owding anged om 1 o 8 mm in he maxilla y and om 0.5 o 8.0 mm in he mandibula a ch. The mos equen c owding was 2 mm in he maxilla y and 1 mm in he mandibula a ch (6.9% and 11.5%, espec i ely). Compa ed o boys, gi ls had 1.6 imes g ea e odds o ha ing c owding, and smalle odds o ha ing canine end‐ o‐ end, o e je ≥3.5 mm, and class II mola ela ionship. The wid h o he midline dias ema was mos equen ly 2 mm (20.2%) in he maxilla y a ch ( ange 0.5–4.5 mm) and 0.5 mm ( ange 0.5–4.5 mm) in he mandibula a ch (6.1%). 3.2 |O hodon ic ea men need and complexi y o ea men Acco ding o ICON, 64.3% o Es onian 7‐ o 10‐yea ‐olds we e in need o o hodon ic ea men (ICON sco e > 43). The sco es anged om 7 o 105 (median sco e 50), he mos equen sco e being 44 (11.2%). The e we e no gende di e ences in ea men need (χ 2 (1) = 1.7, p= .21). Dis ibu ion o ea men complexi y is p esen ed in Table 2. 3.3 |Pa en s' iews and o hodon ic ea men need App oxima ely 65.6% o he pa en s we e sa is ied o e y sa is ied wi h hei child's den al heal h. The associa ion be ween pa en s' sa is ac ion and objec i e ea men need was s a is ically signi ican (χ 2 (3) = 12.83, p= .005). Mo e han hal o he pa en s (53.1%) we e sa is ied o e y sa is ied wi h he alignmen and appea ance o hei child's ee h. Sa is ac ion wi h he alignmen o a child's ee h and pa en s' assessmen o o hodon ic ea men need we e s a is ically signi ican ly associa ed (χ 2 (4) = 19.78, p< .001). App oxima ely 66.4% o pa en s el ha hei child needed o hodon ic ea men , mainly o imp o emen o den al appea ance (37.1%), educ ion in he amoun o ca ies (23.1%), and ease o cleaning (19.6%). App oxima ely 56.5% o child en whose pa en s did no wan o ho- don ic ea men we e in need o o hodon ic ea men acco ding o ICON (Table 3). Pa en s' opinion ega ding ea men need did no di - e o gi ls and boys. A s a is ically signi ican associa ion was ound be ween pa en s' desi e o ge a child's ee h s aigh ened and ea men need as assessed using ICON (χ 2 (1) = 5.59, p= .022). TABLE 1 P e alence o occlusal ai s in 7‐ o 10‐yea ‐old Es onian child en (N= 392) Occlusal ai P e alence (N= 392) % Canine ela ionship Class I 73.7 Class II 3.6 End o end 41.6 Class III 2.3 Symme ic 66.8 Asymme ic 33.2 Mola ela ionship Class I 57.4 Class II 21.9 End o end 54.1 Class III 1.5 Symme ic 64.3 Asymme ic 35.7 Ho izon al ela ionship O e je ≥3.5 mm 37.5 Nega i e o e je 1.0 Ve ical ela ionship O e bi e ≥3.5 mm 51.8 T ans e sal ela ionship Pos e io c ossbi e 10.2 Scisso bi e 1.5 Spacing Midline dias ema 73.0 Maxilla y 57.7 Mandibula 15.3 C owding Uppe and lowe a ch 49.7 Maxilla y 18.9 Mandibula 37.9 TABLE 2 Dis ibu ion o o hodon ic ea men complexi y in 7‐ o 10‐yea ‐old Es onian child en de e mined wi h ICON Complexi y ICON sco es Gi ls (N= 198) Boys (N= 194) To al (N= 392) N%N%N% Simple and mild <50 112 56.6 89 45.9 201 51.3 Mode a e 51–63 40 20.2 49 25.3 89 22.7 Di icul 64–77 28 14.1 27 13.9 55 14.0 Ve y di icul >77 18 9.1 29 14.9 47 12.0 No e. ICON = index o complexi y, ou come, and need. SEPP ET AL.95 4|DISCUSSION This s udy is he i s popula ion‐based s udy egis e ing occlusal ai s and o hodon ic ea men need among 7‐ o 10‐yea ‐olds in Es onia. The la ges e hnic g oups in Es onia a e Es onians (68% o he popula ion) and Russians (28%); he emaining 4.0% consis o 142 o he e hnici ies. Fo p ac ical easons, sampling was done in ci ies. Child en we e andomly selec ed and can be conside ed ep esen a i e o hose ci ies' child popula ion. We ha e no eason o belie e ha he si ua ion in he coun yside o in o he ci ies is di e en , because Es onia has nei he big ci ies and slums no long dis ances be ween popula ion cen es. Any possible egional di e ences in Es onia and hei possible co ela ion o he socioeconomic s a us o amilies need o be assessed in u u e s udies. This s udy con i med ea lie indings, namely, ha he mos equen sagi al ela ionship is class I in he i s mola s and class I in canines. Wo h no ing is ha a he age o 7‐ o 10 yea s, asymme ic sagi al mola and canine ela ionships we e equen in Es onian child en. Asymme y o la e ali y (di ec ional asymme y) is a common inding in many c anio acial s uc u es (Pi iniemi & Kan omaa, 1992). Decay, ea ly loss o he deciduous ee h, disc epancy in oo h size and quan i y, de angemen s in he empo omandibula join , o asymme ic habi s may c ea e asymme ic occlusal de elopmen (Moo ees, 1959; Thilande & Rönning, 1985). P e alence o class II mola ela ionship was 21.9%, which is in line wi h he p e alence epo ed om o he coun ies, 9.2–28.0% in mixed den i ion (Dimbe g, Lenna sson, Söde eld , & Bondema k, 2013; Lux, Dücke , P i sch, Komposch, & Niekusch, 2009; Myllä niemi, 1970). In pa , he a iabili y may be ela ed o di e ences in applied c i e ia and in he in e p e a ion o indings. Mos s udies ha e no di e en ia ed be ween sagi al symme y and asymme y. The ange o o e je in 7‐ o 10‐yea ‐old Es onian child en was simila o ha o 9‐yea ‐old child en in Ge many (Lux e al., 2009), bu unlike in Ge many, he e was no di e ence be ween boys and gi ls in Es onia. Compa ed wi h Finnish child en, Es onian child en had a highe p e alence o an inc eased o e je in mixed den i ion (Myllä niemi, 1970). I is possible ha Es onian child en wi h an o e je o ≥6 mm would bene i om ea ly o hodon- ic ea men (A un & Al‐Azemi, 2009; Jä inen, 1978). The ecen Coch ane Re iew also concludes ha ea ly o hodon ic ea men is e ec i e, o example, in educing he incidence o incisal auma (Thi u enka acha i, Ha ison, Wo hing on, & O'B ien, 2013). The equency o nega i e o e bi e was simila in Es onian and Finnish child en bu clea ly lowe han in a Swedish sample o 7‐ yea ‐olds, whe e hose wi h e up ing inciso s had al eady been excluded om analyses (Dimbe g e al., 2013). Despi e he a i y o c ossbi e and scisso bi e, hey should be moni o ed o . Ea ly ea men may p e en de elopmen o occlusal dys unc ion and asymme ical g ow h (Pi iniemi & Kan omaa, 1992; Thilande , Wahlund, & Lenna sson, 1984). In he age g oup o 7‐ o 10‐yea ‐olds, he younges child en we e jus en e ing o ea ly mixed den i ion, whe eas some 10‐yea ‐olds al eady had pe manen den i ion. Hence, conside a ions o in e sep i e p ocedu es ange om assis ing p ope e up ion o inci- so s and i s mola s o spacing o c owding and skele al ela ionships. All den is s ace hese occlusal ai s in yea ly den al examina ions. In addi ion, he equen asymme ic sagi al ela ionships obse ed in his s udy b ing addi ional challenge o o hodon ic planning. In his age g oup, he e exis s no gene ally accep ed ea men need index, quick o apply, and use in assessmen o plas e cas s. Despi e he ac ha ICON is designed o la e‐mixed den i ions (Daniels & Richmond, 2000), we used i o assessmen o o hodon- ic ea men need. I s assessmen s a e clea ly de e mined and i also p o ides da a on ea men complexi y. The 10 included pho o- g aphs Aes he ic Componen o he Index o O hodon ic T ea men Need (AC/IOTN) ep esen sligh ly olde child en. Howe e , hey can easily be used as a e e ence o he le el o den al aes he ics; he e is no in en ion o poin ou a simila den i ion o he one ha he child has bu o selec he pho og aph wi h as pleasing an occlusion. As a ma e o ac , he e is no pho og aph ep esen ing, o exam- ple, nega i e o e bi e o class III ela ionship. In he u u e, he ICON sco es will be compa able wi h hose o he olde age g oup o Es onian adolescen s. Al hough ICON is use ul in assessing ea - men need, i does no assis in planning he iming o ea men , which is an impo an aspec o paedia ic o hodon ic ca e. Gi ls seem o pay mo e a en ion o hei appea ance and a e mo e in e es ed in o hodon ic ea men han boys (Bi keland, Bøe, & Wis h, 2000; Jung, 2010). In Es onia, pa en s' opinions we e no TABLE 3 Pa en s' sa is ac ion wi h hei child's den al heal h, and alignmen o ee h, and hei opinion on ea men need as compa ed o an assessmen using ICON (7‐ o 10‐yea ‐old Es onian child en; N= 392) T ea men need To al ICON ≤43 (N) ICON >43(N)N% Sa is ac ion wi h child's den al heal h Ve y sa is ied 11 10 21 5.4 Sa is ied 95 141 236 60.2 I don' ca e 0 1 1 0.3 Somewha dissa is ied 30 78 108 27.6 Ve y unsa is ied 2 17 19 4.8 I don' know 0 1 1 0.3 No answe 2 4 6 1.5 To al 140 252 392 100.0 Sa is ac ion wi h he alignmen o child's ee h Ve y sa is ied 8 8 16 4.1 Sa is ied 86 106 192 49.0 Somewha dissa is ied 35 117 152 38.8 Ve y unsa is ied 3 3 6 1.5 I don' know 7 16 23 5.9 No answe 1 2 3 0.8 To al 140 252 392 100.0 Child needs o hodon ic ea men De ini ely no 2 3 5 1.3 No, I don' hink so 45 58 103 26.3 Yes, I hink so 63 145 208 53.1 Yes, de ini ely 17 35 52 13.3 No answe 13 11 24 6.2 To al 140 252 392 100.0 No e. ICON = index o complexi y, ou come, and need. 96 SEPP ET AL. in luenced by he child's gende . Fu u e s udies should assess he age a which Es onian child en hemsel es begin o pay a en ion o occlusal ai s and den al appea ance. As de e mined wi h ICON, o hodon ic ea men need in Es onia is highe han epo ed in epidemiological s udies om La ia and Fin- land (Heikinheimo, 1978; Liepa, U ane, Richmond, & Duns an, 2003). The expec a ions and wishes o pa en s a e in line wi h ICON, pa ly because he index is sensi i e o isible de ia ions. This s udy con i ms ea lie indings (Bi keland e al., 2000; Kiekens, Mal ha, an' Ho , & Kuijpe s‐Jag man, 2006) ha pa ien s' main expec a ions ega ding o hodon ic ea men a e ela ed o imp o emen in den o acial aes- he ics. This s udy ills a signi ican knowledge gap in o al heal h in Es onia by p o iding an o e iew o den al ai s among 7‐ o 10‐ yea ‐old child en. 5|CONCLUSION The p esen esul s indica e ha • he mos p e alen occlusal ai s we e class I canine sagi al ela ionship, midline dias ema, class I mola sagi al ela ionship, and inc eased o e bi e; •mo e han hal o Es onian child en had an asymme ical canine and mola ela ionship; •acco ding o ICON, 64.3% o Es onian 7‐ o 10‐yea ‐olds we e in need o o hodon ic ea men ; •a s a is ically signi ican associa ion was ound be ween pa en s' desi e o s aigh en hei child's ee h and ea men need assessed using ICON. Pa en s' opinion ega ding o hodon ic ea men need did no di e in a s a is ically signi ican way on he basis o he child's gende ; and • he pa en s' main expec a ion om o hodon ic ea men was imp o emen in den o acial aes he ics. ACKNOWLEDGMENTS We hank he pa icipan s o he s udy o hei impo an con ibu ions. REFERENCES A un, J., & Al‐Azemi, R. (2009). 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Clin Exp Den Res. 2017;3:93–99. h ps://doi.o g/10.1002/ c e2.64 APPENDIX A REGISTRATION CRITERIA OF OCCLUSAL TRAITS IN THE CLINICAL EXAMINATION AND FROM THE PLASTER CASTS A.1. |Sagi al plane The sagi al ela ionship o he i s pe manen mola s was egis e ed be ween pe pendicula p ojec ions, on he occlusal plane, om he ip o he iangula idge o he mesiobuccal cusp o he maxilla y i s pe manen mola and he buccal g oo e o he mandibula i s pe ma- nen mola . Mola class I: he iangula idge a icula ed in he buccal g oo e o he mandibula i s pe manen mola . Mola class II: he iangula idge a icula ed an e io o he mesial g oo e o he mandibula i s pe manen mola . Mola class III: he iangula idge a icula ed pos e io o he mesial g oo e o he mandibula i s pe manen mola . End o end: he iangula idge o he mesiobuccal cusp o he maxilla y i s pe manen mola a icula ed o he iangula idge o he mesiobuccal cusp o he mandibula i s pe manen mola . Mola classes II and III we e egis e ed in he accu acy o ≥1/2 cusp wid h. In cases o ob ious oo h mig a ion, no a emp was made o endea ou he o iginal in e cuspa ion. Regis a ion was no done when he i s mola was missing. The sagi al ela ionship o he canines was measu ed be ween pe pendicula p ojec ions, on he occlusal plane, om he ip o he maxilla y canine and he con ac poin o he mandibula canine and he i s deciduous mola o he i s p emola . Canine class I: he ip o he maxilla y canine occluded o he dis al su - ace o he mandibula canine. Canine end o end: he ip o he maxilla y canine a icula ed o he ip o mandibula canines. A de ia ion o 1 mm o mo e o he mesial o dis al was classi ied as canine class II o I, espec i ely. Canine class III: he ip o he maxilla y deciduous canine occluded mo e han 1 mm pos e io o he dis al su ace o he mandibula canine In he case o missing canine, he egis a ion was no eco ded. No a emp was made o compensa e o d i o ee h due o p ema- u e ex ac ion o any o he easons. A.2. |Ho izon al plane The o e je (posi i e) was measu ed in 0.5‐mm in e als as he ho i- zon al dis ance, pa allel o he occlusal plane, om he mos labial su - ace o he lowe cen al inciso s o he mos labial poin o he incisal edge o he co esponding uppe inciso s. In case bo h uppe o lowe cen al inciso s we e missing, he la e al inciso was used. A nega i e o e je was measu ed in 0.5‐mm in e als as he ho i- zon al dis ance, pa allel o he occlusal plane om he mos labial su - ace o he uppe cen al inciso o he mos labial poin o he incisal edge o he co esponding lowe cen al inciso s. A.3. |Ve ical plane The o e bi e (posi i e) was measu ed in 0.5‐mm in e als as he dis- ance be ween he p ojec ion o he edge o he mos o e lapped cen- al inciso on he labial su ace o he lowe inciso s (in cen ic occlusion) and he incisal edge o he lowe inciso . A nega i e o e bi e o open bi e was eco ded when he e exis ed a e ical space be ween he uppe and lowe incisal edges in he cen- ic occlusion. The nega i e o e bi e was measu ed in 0.5 mm in e als om he incisal edge o he lowe inciso s o he incisal edge o he uppe co esponding inciso s. A.4. |T ans e sal plane The pos e io c ossbi e was egis e ed in he canine, p emola , and mola a ea when he buccal cusp o he maxilla y oo h occluded lin- gual o he buccal cusp o he mandibula an agonis s (a leas one pai o ee h). Tee h in an end‐ o‐end posi ion we e egis e ed as c ossbi e. A scisso bi e was eco ded in he p emola and mola a ea when lingual cusps o maxilla y ee h occluded buccally o he buccal su - aces o co esponding mandibula ee h. A.5. |C owding C owding o he ee h was es ima ed as o al space de iciency (in mil- lime e s) o he an e io ee h (inciso s only). The amoun o c owding was eco ded in he maxilla y and mandibula a ch as he di e ence be ween he o al mesio‐dis al oo h diame e and he a ch ci cum e - ence. The possible in luence o g ow h in a ch wid h was no es ima ed. A.6. |Midline dias ema Midline dias ema be ween he cen al inciso s in he uppe and lowe a ch was measu ed in 0.5‐mm in e als be ween he mesial ma gin o he igh and le inciso s on he middle heigh o he oo h c own. 98 SEPP ET AL. APPENDIX B QUESTIONNAIRE 1. How sa is ied a e you wi h he den al heal h o you child? Ve y sa is ied/Sa is ied/I don' ca e/Somewha dissa is ied/Ve y unsa is ied/I don' know 2. How sa is ied a e you wi h he alignmen o you child's ee h? Ve y sa is ied/Sa is ied/Somewha dissa is ied/Ve y unsa is ied/I don' know 3. Do you hink ha you child needs o hodon ic ea men ? De ini ely no /No, I don' hink so/Yes, I hink so/Yes, de ini ely 4. Fo wha eason would you like o align you child's ee h? To imp o e hei appea ance/To imp o e hei unc ion/Fo ease o cleaning/To educe ca ies/O he easons/I don' know 5. Has you child e e wo n an o hodon ic appliance o is you child wea ing one now? Yes/No/I don' know SEPP ET AL.99