Received: 28 November 2018 Revised: 11 January 2019 Accepted: 14 January 2019
DOI: 10.1002/cre2.170OR I G I N A L A R T I C L EOcclusal traits of 4–5‐year‐old Estonians. Parents'
perception of orthodontic treatment need and satisfaction
with dental appearanceHettel Sepp1 | Mare Saag1 | Heli Vinkka‐Puhakka2 | Anna‐Liisa Svedström‐Oristo2 |
Timo Peltomäki31Department of Stomatology, Faculty of
Medicine, University of Tartu, Tartu, Estonia
2Department of Oral Development and
Orthodontics, Institute of Dentistry,
University of Turku, Turku, Finland
3Oral and Maxillofacial Unit, Tampere
University Hospital, and Faculty of Medicine
and Life Sciences, University of Tampere, and
Institute of Dentistry, Faculty of Health
Sciences, University of Eastern Finland,
Kuopio, Finland
Correspondence
Hettel Sepp, Department of Stomatology,
Faculty of Medicine, University of Tartu,
Raekoja pl. 6, Tartu 51003, Estonia.
Email: hettel@hettel.ee- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
This is an open access article under the terms of th
the original work is properly cited.
©2019 The Authors. Clinical and Experimental De
We declare of originality of our authorship of this
conflict of interest.
Clin Exp Dent Res. 2019;1–6.Abstract
This study aims to evaluate the prevalence of occlusal traits and to assess
parents'/caregivers' satisfaction with child's dental appearance and perception of
orthodontic treatment need in 4–5‐year‐old Estonians. Clinical records and plaster
casts of 390 children (190 girls and 200 boys, mean age 4.7 years, range 4 ̶ 5 years)
were analyzed. Assessed occlusal traits included deciduous canine and second molar
sagittal relationship, overjet, overbite, crowding, midline diastema, crossbite, and scis-
sor bite. Parents'/caregivers' opinions regarding their child's teeth were determined
with a questionnaire. The most prevalent occlusal traits were symmetrical sagittal
relationship in deciduous canines (78.2%) and molars (75.1%), Class I sagittal relation-
ship in deciduous canines (69.7%) and midline diastema (67.7%). Asymmetrical sagittal
canine relationship was registered in 21.8% deciduous canines and in 24.9% second
deciduous molars. Parents'/caregivers' perceived orthodontic treatment need was
related to Class III sagittal relationship in canines, increased overjet and overbite, nega-
tive overbite, and crossbite. Prevalence of most occlusal traits in Estonian children
were in line with those reported in neighboring countries. Parents/caregivers were
well able to observe occlusal traits that deviated from acceptable occlusion.
KEYWORDS
occlusal traits, perception, satisfaction, treatment need1 | INTRODUCTION
Childhood is an important period in growth and development of the
craniofacial area and teeth. Fully erupted deciduous dentition pro-
vides prognostic features from the standpoint of the future develop-
ment of permanent dentition. The benefit of guiding interceptive- - - - - - - - - - - - - - - - - - - - - - - - - - -
e Creative Commons Attribution Li
ntal Research published by John W
manuscript and assure of anyinterventions and preventive measures in deciduous and mixed denti-
tion has been debated for several decades (Bishara, Hoppens,
Jakobsen, & Kohout, 1988; Freeman, 1977; Hixon, 1968; Lavelle,
1976; Leighton, 1970; Sonnesen, Bakke, & Solow, 2001; Thilander,
Rubio, Pena, & de Mayorga, 2002). Marked individual variation in
growth and development of the jaw, however, complicates the prog-
nosis of occlusal development (Amini, Hamedi, Haji Ghadimi, &
Rakhshan, 2017; Horowitz & Hixon, 1966; Leighton, 1975; Solow,
1980; Thilander, 2009).- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
cense, which permits use, distribution and reproduction in any medium, provided
iley & Sons Ltd.
wileyonlinelibrary.com/journal/cre2 1
FIGURE 1 The flow chart describing refining of the final sample
2 SEPP ET AL.Moorrees (1959) has provided a baseline analysis of longitudinal
dental development between ages 3 and 18. Cross‐sectional studies
of occlusal traits in different age groups give an overall picture of
dental development in the population and assist in recognizing the
individuals in need of closer follow‐up (Brunelle, Bhat, & Lipton,
1996; Thilander, Pena, Infante, Parada, & de Mayorga, 2001).
Nevertheless, it has recently been shown that, in addition to
secular trends that influence dental development, there are also
population‐specific occlusal traits (Eskeli et al., 2016; Kerosuo, Laine,
Nyyssonen, & Honkala, 1991).
This study is the third in a series of cross‐sectional investigations
analyzing the prevalence of occlusal traits in Estonians between the
ages of 4 and 21 years.
The aims of this study were to evaluate
• The distribution of occlusal traits in Estonian 4–5‐year‐olds.
• Parents'/caregivers' satisfaction with their children's dental
appearance and their perceptions on orthodontic treatment need
in this age group.
Work hypotheses of this study were that
• The prevalence and types of occlusal traits in Estonia do not differ
significantly from those in neighboring countries in the age group
of 4–5 years.
• Occlusal traits observed by parents/caregivers differ from those
observed by orthodontic professionals.2 | SUBJECTS AND METHODS
2.1 | Data source
A 95% confidence interval around an estimate (±2.5% of the estimate)
was specified for sample size calculation. In the sampling, a
multistage stratified cluster design was implemented. Recruitment of
4–5‐year‐old children was started in March 2011 and completed in
January 2012. All of the 4–5‐year‐old children from 11 selected
kindergartens—five in North Estonia, four in Central Estonia, and
two in Southwest Estonia—were invited to participate in the study.
The number of invited children was 467. A total of 77 children
were excluded for following reasons: (a) 41 children were not in kin-
dergarten on the examination days, (b) 29 parents did not agree their
child to participate in the clinical study (c) six children were too afraid
to participate in the clinical study, and (d) one child had cleft lip and
palate. Thus, the final sample consists of 390 children (190 girls
and 200 boys, mean age 4.7 years, range 4–5 years). The sampling
procedure is illustrated in Figure 1.
Prior to the study, a written description of the study protocol was
given to all parents/caregivers. All parents/caregivers signed an
informed consent form. The study protocol was approved by the
Ethics Review Committee on Human Research of the University of
Tartu (Protocol No. 186T‐24).2.2 | Registration of occlusal traits
The following occlusal traits were registered clinically in centric occlu-
sion by one orthodontist (Examiner 1): (a) sagittal relationships in
deciduous canines and second molars separately for right and left side,
(b) overjet (OJ), (c) overbite (OB), (d) crossbite, and (e) scissor bite.
To obtain centric occlusion, a child was asked to open mouth only
slightly. The orthodontist gently verified that mandible was relaxed,
then the child was asked to bite together.
The examination was carried out in the kindergarten's medical
office using a dental mirror, probe, pencil (0.3 mm), and millimeter
ruler (with 0.5 mm intervals; Dentaurum 042‐751 Münchner Modell).
The clinical study was complemented with alginate impressions for
plaster casts. Preshaped bite registration wax was softened in warm
water bath and placed against the upper dental arch; relaxed mandible
was gently guided into centric occlusion to get indentations of cusps
of lower teeth into registration wax.
Examiners 1 and 2 registered three features from the plaster casts
in consensus: (a) end‐to‐end relationship of the deciduous canines and
second molars, separately for the right and left side, (b) crowding, and
(c) diastemas between central incisors.
Registration of the occlusal traits was based on international stan-
dards (Brunelle et al., 1996; Horowitz & Hixon, 1966; Moorrees, 1959).
A detailed description of the criteria has been presented previously
(Sepp, Saag, Svedström‐Oristo, Peltomäki, & Vinkka‐Puhakka, 2017).2.3 | Questionnaire
Opinions regarding children's general dental health, tooth alignment,
dental appearance, and orthodontic treatment need were collected
with a questionnaire filled in at home by parents/caregivers. More
TABLE 1 Prevalence of occlusal traits in 4–5‐year‐old Estonian
children (N = 390)
SEPP ET AL. 3than one answer per question was allowed. The questionnaire was
modified from one used in a previous study (Pietilä & Pietilä, 1996).Occlusal trait Prevalence (%; N = 390)
Deciduous molar relationship
Mesial terminal plane 47.9
Flush terminal plane 42.8
Distal terminal plane 33.6
Symmetric 75.1
Asymmetric 24.9
Canine relationship
Class I 69.7
End‐to‐end 42.8
Class II 5.6
Class III 3.8
Symmetric 78.22.4 | Reliability and statistical analysis
Twenty‐two children were reexamined clinically by Examiner 1 after a
1‐week interval before the intended study. The reliability was very
good (r > 0.99). A total of 122 plaster casts were reexamined for
calibration after 1 month by Examiners 1 and 2 together. The
reliability was very good (r > 0.98). Chi2 and Fisher's exact test (where
necessary) were used to compare the frequencies of occlusal traits
(IBM SPSS v.20 software for Windows [IBM Corp, Armonk, NY,
USA]). p values of less than 0.05 were considered statistically signifi-
cant. The test–retest was calculated using Pearson's correlations
(r = 0.72, p < 0.01).Asymmetric 21.8
Horizontal relationship
Overjet ≥ 3.5 mm 15.6
Overjet < 0 mm 2.3
Vertical relationship
Overbite ≥ 3.5 mm 38.7
Overbite < 0 mm 3.1
Transversal relationship3 | RESULTS
In the current study, there were a total of 28 children (7.2%) with
symmetrical flush terminal plane and Class I in deciduous canines, OJ
1–3 mm and OB 1–3 mm, no crowding, scissor bite or crossbite. Of
their parents/caregivers, 23 (85.2%) were satisfied with the alignment
of teeth.
Posterior crossbite 17.4
Scissor bite 0.5
Midline diastema
Upper and lower arch 34.9
Maxillary 46.9
Mandibular 55.6
Crowding
Upper and lower arch 0.0
Maxillary 0.0
Mandibular 0.33.1 | Occlusal traits
The most prevalent occlusal traits were symmetrical relationship in
deciduous canines (78.2%) and molars (75.1%), Class I sagittal relation-
ship in deciduous canines (69.7%) and midline diastema (67.7%)
(Table 1).
Asymmetrical sagittal relationship in deciduous canines was found
in 21.8% and in second deciduous molars in 24.9% of the examinees
(Figure 2). Children with asymmetric end‐to‐end sagittal relationship
in canines had statistically significantly more crossbites compared with
children with symmetric end‐to‐end sagittal relationship (p < 0.01).
The OJ ranged from −4.0 mm to 7.0 mm (mean 2.1 mm, SD 1.4)
and the OB from −5.0 mm to 6.5 mm (mean 2.7 mm, SD 1.7) (Figure 3).
A statistically significant gender difference was found in OJ. Boys had
on average larger OJ than girls (boys 2.2 ± 1.4 vs. girls 1.9 ± 1.4,
p < 0.01), and there was a trend of more boys with increased OJ
(OJ ≥ 3.5 mm) compared with girls (p = 0.06).
Of children with negative OJ (OJ < 0 mm), 24.2% had Class III
sagittal relationship in canines unilaterally or bilaterally. OJ and OB
were statistically significantly larger in children with distal terminal
plane (OJ 1.8 vs. 2.6, OB 2.4 vs. 3.3, p < 0.01) compared with those
with Class II sagittal relationship in canines (OJ 2.0 vs. 3.1, OB 2.6
vs. 4.0, p < 0.01), end‐to‐end canine sagittal relationship (OJ 1.8 vs.
2.5, OB 2.5 vs. 3.0, p < 0.01), and those without crossbite (OJ 2.2
vs. 1.2, OB 3.1 vs. 1.2, p < 0.01).
The midline diastema ranged from 0.1 to 6.0 mm. In the lower
arch, it was statistically significantly smaller in children with distal ter-
minal plane of deciduous molars (0.5 vs. 0.7, p = 0.02), Class III sagittal
relationship in canines (0.6 vs. 1.1, p = 0.01), and those with crossbite
(0.6 vs. 0.8, p = 0.03).Posterior crossbite was observed in 6.7% on the right side, in
4.3% on the left side, and in 6.4% on both sides. One child had a scis-
sor bite on the right and one on the left side. None of the children had
bilateral scissor bite.3.2 | Parents'/caregivers' satisfaction
The children whose parents/caregivers were satisfied with the
arrangement of their child's teeth had significantly less scissor bite
(p = 0.02), increased OB (p = 0.01), negative OB (p < 0.01), and Class
III sagittal relationship in canines (p = 0.05), compared with children
whose parents were dissatisfied with the arrangement of their child's
teeth (Table 2).3.3 | Parents'/caregivers' opinions on orthodontic
treatment need in 4–5‐year‐old children
All parents whose child had Class III sagittal relationship in canines,
increased OJ (OJ threshold ≥4 mm) and OB (OB threshold ≥4 mm),
FIGURE 2 Distribution of sagittal
relationship of the second deciduous molars
and deciduous canines in 4–5‐year‐old
Estonian girls (black) and boys (gray) (N = 390).
Gender difference was present only for mesial
terminal plane (*p < 0.05)
FIGURE 3 The range of overjet (black) and overbite (gray) in 4–5‐year‐old children in Estonia (N = 390)
4 SEPP ET AL.negative OB, and crossbite thought their child was in need of ortho-
dontic treatment.
Reduction in the amount of caries was highlighted most often by
parents/caregivers as a reason for orthodontic treatment (52.5%).
They were also more likely to want improvement in function if the
children had crossbite (27.0% vs. 16.0%, p = 0.01) (Table 3).4 | DISCUSSION
Data on distribution of occlusal traits, on parents'/caregivers' satisfac-
tion with dental appearance, and their opinions on orthodontic treat-
ment need in 4–5‐year‐old children have been lacking in Estonia.
In Estonia, the prevalence of mesial terminal plane was much
higher than in Finland (47.9% vs. 19.1%, respectively) (Keski‐Nisula,
Lehto, Lusa, Keski‐Nisula, & Varrela, 2003). Variability in deciduous
molar sagittal relationship may be partly related to subjectivity in its
definition. Indeed, the canine sagittal relationship has proved to be
more reliable than that of molars. Although the prevalence of ClassIII sagittal relationship in canines was lower in Estonia than in Sweden
(3.8% vs. 9.0%) (Dimberg, Lennartsson, Söderfeldt, & Bondemark,
2013), it was higher than in Finland (1.5%) (Keski‐Nisula et al., 2003).
However, these values may possibly include some canine Class I
relationship because all the occlusal traits in our study were assessed
using central occlusion as the reference. In fact, at the age of
4–5 years, ongoing development of temporomandibular joints makes
definition of centric relation more or less unreliable (Karlo et al., 2010).
Distribution of symmetric and asymmetric sagittal molar relation-
ships in Estonian children was in line with that of Finnish children
(Keski‐Nisula et al., 2003).
In our study, the prevalence of posterior crossbite was signifi-
cantly higher in children with asymmetrical than symmetrical sagittal
relationship. Prevalence of bilateral crossbite in Estonians was equal
to that of Swedes (Dimberg et al., 2013) but higher than that of
Finnish children (Keski‐Nisula et al., 2003). However, the prevalence
of negative OJ in this study was similar to that in Finland as well as
Sweden (Dimberg et al., 2013; Keski‐Nisula et al., 2003).
TABLE 2 Prevalence of occlusal traits and parents'/caregivers' opinions regarding their children's dental health and the appearance and align-
ment of their teeth (N = 390)
Girl Boy Total
N % N % N %
Prevalence of occlusal traits
Posterior crossbite 31 16.3 37 18.5 68 17.4
Overjet <0 mm 6 3.2 3 1.5 9 2.3
Overbite <0 mm 5 2.6 7 3.5 12 3.1
Overjet ≥4 mm 18 9.5 29 14.5 47 12.1
Overbite ≥4 mm 54 28.4 53 26.5 107 27.4
Canine Class III 8 4.2 7 3.5 15 3.8
Satisfaction with child's dental health
Very satisfied 44 23.2 25 12.5 69 17.7
Satisfied 112 58.9 120 60.0 232 59.5
I do not care 1 0.5 2 1.0 3 0.8
Dissatisfied 26 13.7 40 20.0 66 16.9
Not satisfied at all 5 2.6 11 5.5 16 4.1
I do not know 2 1.1 2 1.0 4 1.0
Total 190 100.0 200 100.0 390 100.0
Satisfaction with the alignment and appearance of child's teeth
Very satisfied 40 21.1 29 14.5 69 17.7
Satisfied 114 60.0 143 71.5 257 65.9
Dissatisfied 21 11.1 17 8.5 38 9.7
Unhappy 0 0.0 1 0.5 1 0.3
I do not know 14 7.4 6 3.0 20 5.1
No answer 1 0.5 4 2.0 5 1.3
Total 190 100.0 200 100.0 390 100.0
Desire for orthodontic treatment
Definitely not 18 9.5 14 7.0 32 8.2
No, I do not think so 119 62.6 125 62.5 244 62.6
Yes, I think so 36 18.9 33 16.5 69 17.7
Yes, definitely 1 0.5 3 1.5 4 1.0
No answer 16 8.4 25 12.5 41 10.5
Total 190 100.0 200 100.0 390 100.0
SEPP ET AL. 5The prevalence of midline diastema in 4–5‐year‐olds (67.7%)
reflected that of 7–10‐year‐old Estonians (73.0%) (Sepp et al., 2017).
This finding conforms with the idea that the structure of the frenulum
influences the position of central incisors.
Estonian children had a lower prevalence of increased OJ
(OJ > 4 mm) compared with Finnish and Swedish children (Dimberg
et al., 2013; Keski‐Nisula et al., 2003). Instead, prevalence of increased
OB (OB > 4 mm) (27.0%) of Estonian children was in line with that of
Finnish children (34.0%) (Keski‐Nisula et al., 2003).TABLE 3 The reasons for parents' desire for orthodontic treatment
in 4–5‐year‐old Estonian children (N = 390)
Reason N %
To reduce the amount of caries 84 52.5
To improve dental appearance 27 16.9
To improve occlusal function 21 13.1
Other reason 17 10.6
To facilitate cleaning 11 6.9
Total 160 100.0There was no crowding in any of the studied 4–5‐year‐old Esto-
nians. This finding is contrary to the situation in Finland, where
crowding in the maxilla has been found in 11.6% and in the mandible
in 38.9% of children (Keski‐Nisula et al., 2003). The difference was
clear, although crowding was measured on plaster casts in both of
these studies.
Benefit of orthodontic treatment is estimated by a dentist using
professional criteria. Patients/parents/caregivers make their own
observations, which are equally important in judgment of treatment
need and outcome. Therefore, it is important to know how
parents/caregivers, as laypersons, observe dentition and how critical
they are (Ryan & Cunningham, 2018).What this paper adds?
• Prevalence of most occlusal traits in Estonian 4–5‐year‐olds is in
line with those reported in neighboring countries, except for nega-
tive OB, increased OJ, and lack of crowding.
6 SEPP ET AL.• The most prevalent occlusal traits in Estonian 4–5‐year‐olds are
symmetrical sagittal relationship in deciduous canines and molars,
Class I sagittal relationship in deciduous canines, mesial terminal
plane in deciduous second molars, and midline diastema.
• With regard to dental health and appearance, more than four out
of five parents/caregivers are satisfied. Dissatisfied parents seem
to focus on occlusal traits like negative OB, deep bite, and Class
III relationship in canines.
• The hypothesis that parents/caregivers do not pay attention to
professionally important traits in their child's dentition is rejected.Why this paper is important for dentists?
• It is important to know that the majority of 4–5‐year‐old children
have occlusal traits that may develop into malocclusion.
• Dental professionals should appreciate parents'/caregivers' obser-
vations regarding their child's occlusal traits and functioning of the
masticatory system. They seem to be well able to observe occlusal
traits and functions that deviate from the so‐called “normal.”ACKNOWLEDGEMENTS
We thank the participants of the study for their important
contributions.
ORCID
Hettel Sepp https://orcid.org/0000-0002-7581-1241
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How to cite this article: Sepp H, Saag M, Vinkka‐Puhakka H,
Svedström‐Oristo A‐L, Peltomäki T. Occlusal traits of 4–5‐
year‐old Estonians. Parents' perception of orthodontic treat-
ment need and satisfaction with dental appearance. Clin Exp
Dent Res. 2019;1–6. https://doi.org/10.1002/cre2.170