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
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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). Social and beha io al isk ac o s o max-
illa y inciso auma in an adolescen A ab popula ion. Den al
T auma ology,25, 589–593.
Bi keland, K., Bøe, O. E., & Wis h, P. J. (2000). Rela ionship be ween
occlusion and sa is ac ion wi h den al appea ance in o hodon ically
ea ed and un ea ed g oups. A longi udinal s udy. Eu opean Jou nal
o O hodon ics,22, 509–518.
B unelle, J. A., Bha , M., & Lip on, J. A. (1996). P e alence and dis ibu ion
o selec ed occlusal cha ac e is ics in he US popula ion, 1988–1991.
Jou nal o Den al Resea ch,75, 706–713.
Daniels, C., & Richmond, S. (2000). The de elopmen o he index o
complexi y, ou come and need (ICON). Jou nal o O hodon ics,27,
149–162.
Dimbe g, L., Lenna sson, B., Söde eld , B., & Bondema k, L. (2013).
Malocclusions in child en a 3 and 7 yea s o age: A longi udinal s udy.
Eu opean Jou nal o O hodon ics,35, 131–137.
Giuca, M. R., Capu o, E., Nas asio, S., & Pasini, M. (2011). Co ela ion
be ween o i is media and den al malocclusion in child en. Eu opean
A chi es o Paedia ic Den is y,12, 241–244.
Heikinheimo, K. (1978). Need o o hodon ic ea men in 7‐yea ‐old Finn-
ish child en. Communi y Den is y and O al Epidemiology,6, 129–134.
Ho owi z, S. L., & Hixon, E. H. (1966). The na u e o o hodon ic diagnosis.
(pp. 167–168). Mosby Company: Sain Louis.
Hul c an z, E., & Lö s and‐Tides öm, B. (2009). The de elopmen o sleep
diso de ed b ea hing om 4 o 12 yea s and den al a ch mo phology.
In e na ional Jou nal o Pedia ic O o hinola yngology,73, 1234–1241.
Jä inen, S. (1978). Incisal o e je and auma ic inju ies o uppe pe ma-
nen inciso s. A e ospec i e s udy. Ac a Odon ologica Scandina ica,
36, 359–362.
Jung, M. H. (2010). E alua ion o he e ec s o malocclusion and o ho-
don ic ea men on sel ‐es eem in an adolescen popula ion.
Ame ican Jou nal o O hodon ics and Den o acial O hopedics,138,
160–166.
Ke osuo, H., Hausen, H., Laine, T., & Shaw, W. C. (1995). The in luence o
incisal malocclusion on he social a ac i eness o young adul s in
Finland. Eu opean Jou nal o O hodon ics,17, 505–512.
Ke osuo, H., Väkipa a, M., Nys öm, M., & Heikinheimo, K. (2008). The
se en‐yea ou come o an ea ly o hodon ic ea men s a egy. Jou nal
o Den al Resea ch,87, 584–588.
Kiekens, R. M., Mal ha, J. C., an' Ho , M. A., & Kuijpe s‐Jag man, A. M.
(2006). Objec i e measu es as indica o s o acial es he ics in whi e
adolescen s. The Angle O hodon is ,76, 551–556.
Liepa,A.,U ane,I.,Richmond,S.,&Duns an,F.(2003).O hodon ic
ea men need in La ia. Eu opean Jou nal o O hodon ics,25,
279–284.
Lux, C. J., Dücke , B., P i sch, M., Komposch, G., & Niekusch, U.
(2009). Occlusal s a us and p e alence o occlusal malocclusion
ai s among 9‐yea ‐old schoolchild en. Eu opean Jou nal o O ho-
don ics,31, 294–299.
Miles, P. G., Vig, P. S., Weyan , R. J., Fo es , T. D., & Rocke e, H. E. J .
(1996). C anio acial s uc u e and obs uc i e sleep apnea synd ome—
A quali a i e analysis and me a‐analysis o he li e a u e. Ame ican
Jou nal o O hodon ics and Den o acial O hopedics,109, 163–172.
Monaco, A., Spada o, A., Sgolas a, F., Pe ucci, A., D'And ea, P. D., &
Ga o, R. (2011). P e alence o as igma ism in a paedia ic popula-
ion wi h malocclusions. Eu opean Jou nal o Paedia ic Den is y,
12,91–94.
Moo ees, C. F. A. (1959). The den i ion o he g owing child. (pp. 49–56).
Camb idge, Massachuse s: Ha a d Uni e si y P ess pp. 192–3.
Myllä niemi, S. (1970). Malocclusion in Finnish u al child en. An epidemio-
logical s udy o di e en s ages o den al de elopmen . Thesis. Helsinki,
Uni e si y o Helsinki.
Nisbe , R. E., & Wilson, T. D. (1977). The halo e ec : E idence o
unconscious al e a ion o judgmen s. Jou nal o Pe sonali y and Social
Psychology,35, 250–256.
Pie ilä, T., & Pie ilä, I. (1996). Den al appea ance and o hodon ic se ices
assessed by 15‐16‐yea ‐old adolescen s in eas e n Finland. Communi y
Den al Heal h,13, 139–144.
Pi iniemi, P., & Kan omaa, T. (1992). Rela ion o glenoid ossa mo phology
o mandibulo acial asymme y, s udied in d y human Lapp skulls. Ac a
Odon ologica Scandina ica,50, 235–243.
Ri e , J. M., Casey, R. J., & Langlois, J. H. (1991). Adul s' esponses
o in an s a ying in appea ance o age and a ac i eness. Child
De elopmen ,62,68–82.
Schü z‐F ansson, U., & Ku ol, J. (2008). Rapid maxilla y expansion e ec s
on noc u nal enu esis in child en: A ollow‐up s udy. The Angle
O hodon is ,78, 201–208.
Sil ola, A. S., Rusanen, J., Tol anen, M., Pi iniemi, P., & Lah i, S.
(2012). Occlusal cha ac e is ics and quali y o li e be o e and a e
ea men o se e e malocclusion. Eu opean Jou nal o O hodon ics,
34,704–709.
SEPP ET AL.97

Sunnak, R., Johal, A., & Fleming, P. S. (2015). Is o hodon ics p io o 11
yea s o age e idence‐based? A sys ema ic e iew and me a‐analysis.
Jou nal o Den is y,43, 477–486.
Thilande , B., & Rönning, O. (1985). In oduc ion o o hodon ics (5 h ed.).
(pp. 111). S ockholm: Tandläka ö lage .
Thilande , B., Wahlund, S., & Lenna sson, B. (1984). The e ec o ea ly
in e cep i e ea men o child en wi h pos e io c oss‐bi e. Eu opean
Jou nal o O hodon ics,6,25–34.
Thi u enka acha i, B., Ha ison, J. E., Wo hing on, H. V., & O'B ien, K. D.
(2013). O hodon ic ea men o p ominen uppe on ee h (class
II malocclusion) in child en. The Coch ane Da abase o Sys ema ic
Re iews,11, CD003452.
How o ci e his a icle: Sepp H, Saag M, S eds öm‐O is o
A‐L, Pel omäki T, Vinkka‐Puhakka H. Occlusal ai s and
o hodon ic ea men need in 7‐ o 10‐yea ‐olds in Es onia.
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