Romanian Journal of Oral Rehabilitation

Vol. 8, No. 1, January - March 2016

ORTHODONTIC TREATMENT NEEDS IN MIXED DENTITION -

FOR CHILDREN OF 6 AND 9 YEARS OLD
Anne-Marie Rauten1, Catrinel Georgescu1, M.R. Popescu2, Camelia Fiera Maglaviceanu3, Dora
Popescu4, Dorin Gheorghe4, A. Camen5, Cristina Munteanu5, Madalina Olteanu3
1
Department of Orthodontics, Faculty of Dental Medicine, UMF Craiova
2
Department of Prosthetics, Faculty of Dental Medicine, UMF Craiova
3
Department of Pedodontics, Faculty of Dental Medicine, UMF Craiova
4
Department of Periodontology, Faculty of Dental Medicine, UMF Craiova
5
Department of Oral and Maxillofacial Surgery, UMF Craiova

Correspondent author:

ABSTRACT:
Early identification of a developing malocclusion and initiation of simple orthodontic therapy procedure represent
ways to prevent or reduce the number of late orthodontic treatments, which can be complex, lengthy and costly. We
aimed to assess the need for interceptive therapy of dentomaxillary anomalies on a group of 147 children, 69 of age 6
years old and 78 of age 9 years old, which called for an orthodontic or pedodontic treatment during 2014- 2015 in 4
private offices in Craiova. We observed a high prevalence of caries in temporary and young permanent dentition
(52.98% for age 6 years old and 37.17% for age 9 years old) and of early loss of temporary teeth (17.39% for age 6
years old and 23.07% for age 9 years old). The need for orthodontic treatment was high or very high for 10.13% of
the children age 6 years old and 24.35% of the children age 9 years old, and small or moderate for 13.03% of
children age 6 years old and 33.33% of the children age 9 years old. IOTN can be a valuable tool in identifying,
planning and interception of potential dentomaxillary malocclusions.

Keywords: early loss of temporary teeth; malocclusions; prevention and interception in orthodontics.

INTRODUCTION: other hand it reduces the need for complex or

Need to establish an orthodontic treatment in
children is increased, varying according to the
literature between a quarter and a third of this
population group members [1,2,3,4].
In many cases the development of
dentomaxillary anomalies can be early
detected, since temporary or mixed dentition
[5,6], but many doctors assess subjects in
orthodontic terms only after completion of
dental permutation. Thus they refuse an
interceptive treatment to such patients, which
performed correctly can reduce on the one hand
the risk of developing major dental mismatch,
severe malocclusions or some facial
asymmetries (the potential of skeletal growth
modification is higher at younger ages); on the
lengthy orthodontic treatments, providing a
more stable therapeutic results [7,8,9]. The
interception of malocclusions promotes a better
oral health care and decreases the risk of dental
caries [10,11].
There were described several indices able to
identify people who need orthodontic treatment
and to minimize the subjectivity related to the
diagnosis [12]. Shaw and co-workers (1995)
[13] divided occlusal indices into five different
categories: indices for diagnosis,
epidemiological, orthodontic treatment need,
treatment outcome, and orthodontic treatment
complexity indices. Most of them relate to
permanent dentition. The best known and used
is Index of Orthodontic Treatment Need

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Vol. 8, No. 1, January - March 2016
(IOTN), because it is easily reproducible and
the recording of all the relevant features of
malocclusion can be done in a minute amount
of time [14]. This index has been recommended
and widely used for patients in the full
permanent dentition but not in the mixed
dentition stage [3]. So the IOTN has two
separate components, a clinical component
called the Dental Health Component (DHC)
and an Aesthetic Component (AC). The Dental
Health Component of IOTN is divided into five
grades, with Grade 1 indicating no treatment is
required and Grade 5 showing great need for
treatment (Brook and Shaw, 1989) [15]. The
occlusal trait with the highest score indicates
the grade in which the malocclusion belongs to
determining the degree of treatment needs.
Regarding the aesthetic component it relies on
a series of 10 photographs of different
malocclusion arranged according to their
attractiveness (from the least to the most
attractive). In the original study the scale for
AE assessment was determined by Evans &
Shaw (1987) [16] for a lot of children of age 12
years old. In 2014 Mohamed et al. [1] tried to
assess whether IOTN may find utility in
interception, by assessing occlusal changes in
the frontal maxillary and mandible in a group
of children aged 8-10 years old, concluding that
IOTN is effective in identifying dentomaxillary
anomalies linked to increased overjet and
overbite or to the presence of crossbite.
Specific index for mixed dentition that allows
early detection of developing malocclusion is
the index for preventive and interceptive
orthodontic need, IPION, described by Coetzee
(1997) [17]. IPION consists in recording of
various occlusal traits that have scores
depending on their severity. The trait scores are
then added, yielding a total score that indicates
the need for preventive or interceptive
orthodontic treatment [3]. The index does not
29
show the real prevalence of malocclusion,
however, because there are severe
malocclusions that can not benefit from
preventive or interceptive treatment, which
according to this index, have a low score [3].
It may be possible because of the small number
of studies that have dealt preventive and
interceptive orthodontics over the years and of
the growing interest in this subject in recent
years (Karaiskos et al., 2005 [3]; Silkestrand,
2007 [2] Sandoval and colab.2010 [18]; Borre
2013 [19]; Mohamed et al. 2014 [1]).
The purpose of the present study was to
investigate by means of some occlusal
parameters analysis how necessary is a
preventive or interceptive orthodontic treatment
in several dental officies with private practice
in Craiova, for children aged 6 and 9 years old.
The two age groups were chosen because at 6
years of age starts the mixed dentition phase,
and within this phase the age of 9 years old
marks the beginning of canin-premolar group
eruption, when it completes the arch and
harmonious implanting of permanent teeth into
the alveolar arch and anterior and lateral
guidance in eccentric motion of the mandible
[20].
MATERIAL AND METHOD
The study was conducted during 2014-2015 in
four private dental offices in Craiova with
orthodontics and pedodontic activity. Were
targeted children aged 6 and close to 9 years
old, resulting in a sample of 147 children for
which informed consent was obtained from
caregivers in order to use clinical data records
and analysis of study models and dental
radiographs.
In order to determine the necessity of
establishing a preventive or interceptive
orthodontic treatment depending on the age
 Romanian Journal of Oral Rehabilitation
Vol. 8, No. 1, January - March 2016

they were valued for each child from the study shown in Table 1.by two different examiners.
group more clinical parameters which are
6 year olds 9 year olds

Caries Caries

Early loss Early loss

Molar relationship Molar relationship

Overjet Overjet

Overbite Overbite

Anterior crossbite Anterior crossbite

Posterior crossbite Posterior crossbite

Open bite Open bite

Submerged teeth

Active frenum

Table 1. Analyzed clinical parameters

Molar relationship appreciation was based on
Angle occlusal classification of malocclusions
[21].
The overjet was assessed in millimetres as the
distance between the edge of the upper central
incisor and the labial surface of the lower
central incisor measured in millimeters. Overjet
between 0.1 and 3 mm was considered as
normal, greater than 3 mm was considered as
increased, and 0 mm was taken as edge to edge.
The open bite was measured in millimeters as
the perpendicular distance from the edge of the
central lower to the upper central incisor edge.
The calculated IOTN scores of the 6 and 9 year
old children were mainly based on labial
segment of the upper and lower arches. The
occlusal traits that were scored upon were the
overjet, anterior crossbite, posterior crossbite,
overbite and open bite.
For conformity assessment between clinical
examinations results, the intra-examiner
agreement was set at 10%.
The collected data were statistically analyzed
with the dedicated software (SPSS 16.0,
Chicago, IL, USA). Differences between
groups were calculated using the Mann
Whitney UU test and for correlations among
the groups the Pearson test was used. All
results were tested for statistically significant
differences between age groups and genders
using the χ2 test [22]. Inter- and intra-examiner
agreement was evaluated using the weighted
kappa statistic.
RESULTS
69 patients of the subjects included in the study
were aged around 6 years old (6 years ± 3
months) and about 78 around 9 years old (9

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 Romanian Journal of Oral Rehabilitation
Vol. 8, No. 1, January - March 2016

years ± 6 months). Within the 6 years old

group, 39 (56.52%) were girls and 30 boys
(43.48%) and from those of age 9 years old, 41
(52.56%) were girls and 37 boys (47.44 %).
Caries: In the 6-year-old group, 24% of
children had caries affecting 1 tooth and
28.98% had caries affecting more than 1 tooth;
in the 9 years old group, 16.66% had caries
affecting 1 tooth and 20.51% had caries
affecting more than 1 tooth (table 2).
The most affected tooth by carries was primary
second molar: for 6 years old in 39.47%, and
for 9 years old 37.70% (table 3).
Early loss of temporary teeth: 12 of the 6
years old subjects (17.39%) and 18 of the 9
years old (23.07%) had early loss for ≥ 1 tooth.
The most commonly missing teeth were the
primary first molars (43,75%), followed by the
primary canines (31.25%) for the 6 years old;
in the 9 years old, the primary canines
(46.15%) were most commonly missing,
followed by the primary first molars (19.23%)
(table 4).

No. of No. (and %) No. (and %)

teeth
of 6 years of 9 years old
old

0 32 (47.02%) 49 (62.82%)

1 17 (24%) 13 (16.66%)

≥1 20 (28.98%) 16 (20.51%)

Table 2. Number of teeth affected by caries

No. (and %) No. (and %)

Tooth affected of 6 years of 9 years
old old

Primary incisors 6 (7.89%) 0 (0%)

Primary canines 5 (6.57%) 7 (11.47%)

Primary first molars 23 (30.26%) 18 (29.50%)

Primary second 30 (39.47%) 23 (37.70%)

molars
12 (15.78%) 13 (21.31%)
Permanent first

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Vol. 8, No. 1, January - March 2016

molars

Table 3. Teeth most commonly affected by caries

No. (and %) No. (and %)

Tooth affected of 6 years of 9 years old
old

Primary canine 5 (31.25%) 12 (46.15%)

Primary first molar 7 (43.75%) 9 (34.61%)

Primary second 4 (15.00%) 5 (19.23%)

molar

Table 4. Teeth most commonly affected by early loss

Molar relationship: For 6 years old group
22 subjects (31.88%) could not be included in a
class of malocclusion by Angle because that
they had no erupted first permanent molars, and
for 9 years old group 2 patients (2.56%) to
which early extraction of first permanent
molars did not allow the assessment of this
relationship.
Of the 47 children of 6 years old group with
molar relations, 62.3% had a class I
malocclusion, 32.1% class II and 5.7% class III
by Angle, and of the 76 subjects of 9 years old
group 53.84% showed class I malocclusion,
35.89% class II and 7.69% class III after Angle
(table 5).

No. (and %) No. (and %)

Classification of 6 years of 9 years
old old

Not 22 (31.88%) 2 (2.56%)

measurable
31 (44.92%) 42 (53.84%)
Class I
12 (17.39%) 28 (35.89%)
Class II
4 (5.79%) 6 (7.69%)
Class III

Table 5. Molar relationships by Angle classification

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Overjet: 7 of 6 years old subjects (10.14%) showed an increased overjet, while for the group of 9
years old the number was much higher, 43 subjects (55.12%) (Figure 1).

Figure 1. Number of children with overjet

Overbite: 5 subjects of 6 years old and 37 subjects of 9 years old (47.43%) presented an increased
overbite (7.24%) (Figure 2)

Figure 2. Number of children with overbite

Openbite: 12 of subjects of 6 years old (17.39%) and 9 of the subjects of 9 years old (11.53%)
were diagnosed with open bite (Figure 3).

Figure 3. Number of children with open bite

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Vol. 8, No. 1, January - March 2016

Crossbites: There were found to be more
common in the anterior segment than the
posterior segment for both groups. In the 6
years old group 5.79% (4 subjects) exhibited
anterior crossbite. In the 9 years old group
14.10% (11 subjects) exhibited more than 1
tooth in crossbite.
Posterior crossbites occurred in 4.34% (3
subjects) of the 6 years old children, while in
the 9 years old children the percentage was
8.97% (7 subjects).
Submerged teeth and active fraenum: For
the 9 years old group the percentage of subjects
with submerged teeth and active fraenum was
very small 2.56% (by 2 subjects for each
anomaly).
The IOTN score were mainly based on
occlusal alterations in the labial segment of the
upper and lower arches. 10.13% of the children
from the 6 years old group and 24.35% of the
children from the 9 years old group have a high
or very high need of orthodontic treatment
(table 6).

No. (and %) No. (and %)

IOTN scores
of 6 years old of 9 years old

1 No need for treatment 53 (76.81%) 33 (42.30%)

2 3 (4.34%) 5 (6.41%)
Little need for treatment

3 Moderate need for treatment 6 (8.69%) 21 (26.92%)

4 Great need for treatment 5 (7.24%) 14 (17.94%)

5 2 (2.89%) 5 (6.41%)
Very great need for
treatment

69 (100%) 78 (100%)
Total

Table 6. Distribution of IOTN in relation to labial segment malocclusion

DISCUSSIONS: conflicting views over the need for early

Interceptive orthodontic treatment is generally
defined as treatment aimed to eliminate or
reduce unfavourable ongoing signs of
malocclusion, thus providing favourable
conditions for normal growth [2]. There are
orthodontic intervention. Those who are against
treatment in mixed dentition argue the
existence of clinical situations where the
interceptive treatment does not eliminate the
need for curative treatment [23] and the
shortening of the treatment duration for 2-3

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Vol. 8, No. 1, January - March 2016
years if its onset is delayed after the eruption of
premolars and permanent second molars [5,24].
They sustain that by delaying is can be lost the
moment when the skeletal growth can be
influenced, the dental alveolar can be guided
and bad habits deconditioning is the least
difficult [10,11,24,25]. The need for a complex
fixed orthodontic treatment is significantly
reduced [23,26] and may have an adverse effect
on dental health and surrounding tissues [24].
According to the American Academy of
Paediatric Dentistry (AAPD) [27], factors we
should keep in mind when choosing the
initiating of and orthodontic treatment in mixed
dentition period are: chronological/
mental/emotional age of the patient and the
patient’s ability to understand and cooperate in
the treatment; intensity, frequency, and
duration of an oral habit, parental support for
the treatment, compliance with clinician’s
instructions, craniofacial configuration,
craniofacial growth, concomitant systemic
disease or condition, accuracy of diagnosis
appropriateness of treatment, timing of
treatment.
Among the clinical parameters that we
considered necessary to investigate for
determining which would be the need for
preventive or interceptive methods of
dentomaxillary anomalies, caries were a
common symptom. 52.98% of patients in 6
years old group and 37.17% in 9 years old
group had at least one tooth affected by decay.
This percentage is below the World Health
Organization report, according to which 60-
90% of the school population is affected by
caries [28], but the result should rather be
considered with caution given the low
addressability to private dental offices for
treatment of dental injuries on deciduous teeth.
It must not be forgotten that caries are among
the etiological factors of early loss of deciduous
35
teeth [29]. In our study population-based
sample 17.39% of subjects in 6 years old group
and 23.07% in 9 years old group showed early
loss of more than 1 tooth, these percentages
being consistent with data reported in the
Romanian literature [30]. In turn early loss of
temporary teeth can have varying effects such
as shortness of dental arch [10] up to 4 mm
[31]; early loss of temporary canines can lead
to the collapse of the mandibular anterior
region with subsequent collapse of the
maxillary anterior region [31] and the
emergence of incongruency of permanent front
teeth [10,32], to ectopic eruption [33], staying
in impaction of permanent canine or
interincisive line diversion [32]; early loss of
second temporary molar can result into
migration in the sagittal plane of the first
permanent molar and a molar relationship of
class II or III [34].
In this study the majority of the children were
found to be Class I after Angle, 62.3% of
children in 6 years old group and 53.84% in 9
years old group, like other previous Romanian
studies that found class I malocclusions as the
most common [35-36].
Although the proportion of subjects with
malocclusion class II and III, ranked second
and third as the frequency, is much lower, this
subjects are candidates for interceptive
orthodontic treatment if only to prevent dental
class III to become skeletal [37], or to reduce
the risk of injuries to the upper incisors in
patients with malocclusion class II [38].
The other analyzed occlusal parameters
(previously presented), the overjet, overbite,
open bite, depending on the severity and the
simple presence of the cross bite, may represent
themselves the reason for initiating orthodontic
treatment in mixed dentition. Thus at this stage
of development of teeth the overbite and
overjet may increase with the eruption of
 Romanian Journal of Oral Rehabilitation
Vol. 8, No. 1, January - March 2016

permanent incisors [39], but if overcoat degree

is bigger than 5 mm, we might suspect an CONCLUSIONS
evolution towards covered deep bite [5]. 1. It is possible to identify early development of
Detrimental effects of a deep bite include TMJ progressive malocclusion symptoms since the
problems [40], attrition of the anterior teeth, onset of mixed dentition.
direct trauma of the palatal gingiva and 2. They can be highlighted by IOTN and are in
periodontal problems [41]. A deep bite could agreement with the acronym 'MOCDO' -
also restrict the development of the mandibular missing, overjet, cross bite, displacement and
anterior dentoalveolar process, which is overbite.
difficult to subsequently treat [24]. Open bite 3. Early treatment of these changes can create a
may be accompanied by multiple functional normal occlusal relationship and a balanced
disorders: atypical swallowing of protrusion neuromuscular environment at an early age
type [42], oral breathing, chewing [43] and which helps the normal growth of the facial
phonetic [44] disorders. skeleton.
Anterior cross bite untreated cause attrition to 4. IOTN can be a valuable tool in identifying,
the labial surface of the upper incisor, fractures planning and interception of potential
or mobility of incisor teeth, gingival recession malocclusions.
or temporomandibular joint dysfunction [45-
46]. Untreated lateral cross bite is one of the
etiological factors of a narrow jaw [47], a facial
asymmetry [48], or TMJ dysfunction through
asymmetric condylar growth or as a result of
the side slide of the mandible [49-50].
IOTN scores mainly based on occlusal changes
in labial segment of the upper and lower arches
that we analyzed was 10.13% for children in 6-
year old group and 24.35%for children in 9-
year old group. The IOTN value for 9-year old
group is very similar to that found by Karaiskos
et al. (2005) [3] of 28% for the same age group
based on calculation of IPION and smaller than
the percentage of 33% identified by Kerosuo et
al. (2008) [51] or Al Nimri and Richardson
(2000) [52] based on IOTN determination.

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Vol. 8, No. 1, January - March 2016

Acknowledgment
This paper was published under the frame of the research contract no 835 from 17.07.2014.

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