Orthodontics
NECESSITY FACTORS AND PREDICTORS OF DENTAL CROWDING
TREATMENT
Georgeta ZEGAN1, Cristina Gena DASCLU2, Radu Bogdan MAVRU3,
1
Assoc. Prof., PhD, Dept. Surgery, Faculty of Medical Dentistry, Gr. T. Popa U.M.Ph. Iai
2
Lecturer, PhD, Dept. Preventive Medicine and Interdisciplinarity, Faculty of Medicine, Gr. T. Popa U.M.Ph. Iai
3
Assist. Research, PhD Student, Dept. Surgery, Faculty of Medical Dentistry, Gr. T. Popa U.M.Ph. Iai
4
Lecturer, PhD, Dept. Surgery, Faculty of Medical Dentistry, Gr. T. Popa U.M.Ph. Iai
Corresponding author: georgetazegan@yahoo.com
Abstract
The aim of the study was to identify the significant
necessity and predictive factors of dental crowding treat-
ment, on 422 subjects (165 boys and 257 girls) from the
North-East part of Romania. Correlations have been estab-
lished between dental crowding and age, dentition, Angle
class of malocclusions, the etiological factors, types and
modalities of treatments, and types of orthodontic appli-
ances employed (p<0.05). Application of the chi-square test
provided the necessity factors for the types of dental
crowding treatments (p<0.001), while the Hosmer-Leme-
show test permitted to establish the predictive factors for
the interceptive orthodontic treatment (maxillary expan-
sion for mild and moderate crowdings), the corrective ort-
hodontic treatment (maxillary expansion and orthodontic
extraction for dental crowding with local causes) and also
for the surgical-orthodontic treatment (orthodontic extrac-
tion for mild and moderate crowdings) (p>0.05). The neces-
sity and predictive factors of the treatment were adequate
with age, dentition, severity of crowding and Angle class
of malocclusion.
Keywords: dental crowding, orthodontic treatment, neces-
sity factors, predictors of treatment
1. INTRODUCTION
Dental crowding is characterized by the
negative difference between the necessary space
and the existing space of the teeth on the dental
arches, being possibly a symptom of skeletal
malocclusions. The clinical forms of dental
crowding may be mild, moderate or severe,
depending on their manifestation; in anterior,
intermediary, lateral or posterior position as a
function of location; primary, secondary, tertiary,
combined or transient, as a function of their
etiology. Dental crowding may have general
(crossed heredity or disendocrinopathies),
200
Daniela ANISTOROAEI4
functional or local causes [15]. The frequency of
this anomaly is quite high among people, varying
between 5-80% [69], thus representing the most
frequent cause for which patients address the
specialist.
Orthodontic therapy makes use of a large
range of appliances for solving such problems
and for creating space on the arches: dental
alignment, occlusion and facial aesthetics. The
therapeutical means at hand, differing as a
function of the causes and severity of dental
crowding, represent a priority for the dental
aesthetics of patients [1012]. The literature of
the field proposes numerous studies, analyzing
this anomaly from various aspects, considering
different populations, however the predictive
factors of the dental crowding treatment are
almost inexistent.
The present study starts from the hypothesis
that dental crowding is caused by certain specific
causal factors and that that their prompt removal
may prevent serious subsequent complications.
The objectives of the study were to trace the
characteristics of this anomaly in a population
from the North-East region of Romania, and to
evaluate the mean age of its detection, its clinical
forms, its classes of diagnosis, the associated
anomalies, the etiological causes, the need and
types of treatment to be recommended and the
orthodontic appliances employed. The aim of the
study was to establish the necessity factors for
solving dental crowding and the precision of the
predictive factors for establishing possible
treatment options.2.
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 NECESSITY FACTORS AND PREDICTORS OF DENTAL CROWDING TREATMENT
2. MATERIALS AND METHOD
The retrospective study was conducted on
422 patients with ages between 6-24 years (mean
age: 11.053.175 years), 165 (39.1%) boys with a
mean age of 10.442.739 years and 257 (60.9%)
girls with a mean age of 11.443.373 years. All
patients were from the North-East part of
Romania, 311 (73.7%) of them living in urban
zones and 111 (26.3%) in rural areas. The
criterion of patient selection was dental
crowding associated with the Angle classes of
malocclusions. The subjects with genetic or
endocrine syndromes or with palatine clefts
were excluded. The orthodontic diagnosis was
established by clinical and complementary
exams (plaster cast, panoramic radiographs and
lateral cephalometric radiography). All cases
received orthodontic treatment in the Clinic of
Orthodontics of the Sf. Spiridon Emergency
University Hospital of Iai, Romania, between
1991 and 2010. After having obtained the
informed consent of either patients or of their
parents, the study was conducted according to
the Declaration of Helsinki issued in 1975, and
revised in 2000.
Statistical analysis was performed using the
SPSS 16.0 package (SPSS Inc., Chicago, IL),
calculating the distributions of frequencies, the
descriptive statistical parameters and the
Spearman correlation coefficient between the
categories of variables. The correlation between
the clinical signs and the therapeutical solutions
was established with the cross-tabulation
method, applying the chi-square (2) test. The
significant predictors were identified with a
model of binary logistic regression (B) and the
validity of the model was determined with the
Hosmer-Lemeshow goodness-of-fit test (HL
test), at a significance level p>0.05. To eliminate
the multicollinearity problems, the multiple
correlations among factors was analyzed.
Statistical analysis was conducted at a
significance level of 5% and p<0.05.
International Journal of Medical Dentistry
3. RESULTS
The patients considered for the study were
divided into three age intervals, specific for the
development of dentition and of dental
occlusion: >9 years, 96 (22.7%) patients; between
9-12 years, 199 (47.2%) patients; <12 years, 127
(30.1%) patients. 97 (23.0%) of them presented
early mixed dentition, 154 (36.5%) late mixed
dentition, 158 (37.4%) patients - permanent
young dentition, and 13 (3.1%) patients -
permanent complete dentition.
According to the severity of dental crowding,
118 (28%) cases of mild dental crowding, 228
(54%) cased of moderate dental crowding and
76 (18%) cases of severe dental crowding were
registered, so that 286 (67.8%) cases were
considered in Angle I malocclusion class, 112
(26.5%) cases in Angle II class and 24 (5.7%)
cases, respectively, in Angle III class.
Apart from dental crowding, the patients
presented other associated anomalies: crossbite
- 247 (58.5) cases, deep bite - 184 (43.4%) cases,
and mandibular lateral deviation - 150 (35.5%)
cases.
95.3% of the dental crowdings had local
causes and 4.7% - general causes.
15.9% interceptive orthodontic and 93.1%
corrective (13.5% precocious, 38.6% normal and
41.0% late) treatments have been applied. Space
on the arches was obtained by maxillary
expansion in 44.5% cases, by extractions of
permanent teeth - in 34.6% cases, and by serial
extractions of temporary teeth - in 10.7% cases,
on using removable biomechanical appliances
in 29.9% cases, fixed biomechanical appliances
in 27.5% cases and functional appliances,
respectively, in 1.8% cases.
Statistically significant correlations have been
found between dental crowding and the intervals
of age, type of dentition, Angle class of malocclusions,
etiological factors, types of treatments, modalities
for creating space and types of orthodontic
appliances employed (table 1).
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Georgeta ZEGAN, Cristina Gena DASCLU, Radu Bogdan MAVRU, Daniela ANISTOROAEI

Table 1. Nonparametric correlations between dental crowding and variables

Dental crowding
Variables
Pearson rho p value
Gender 0.061 0.214
Environment 0.040 0.417
Age intervals 0.359** 0.000
Dentition types 0.379** 0.000
Angle class - 0.216* 0.000
Crossbite 0.076 0.241
Overbite 0.068 0.162
Mandibular deviation 0.043 0.383
Causes 0.566*** 0.000
Interceptive treatments 0.215* 0.000
Corrective treatments 0.357** 0.000
Surgical treatments 0.516*** 0.000
Extraction / expansion 0.129* 0.008
Appliance types 0.121* 0.013
*
weak correlation for rho<0.30;
**
average correlation for rho=0.30-0.50;
***
strong correlation for rho >0.50, significant correlations for p<0.05.

The interceptive treatment applied was
specific to the age >9 years (58.2%, 2=68.478,
p=0.000), to early mixed dentition (58.2%,
2=75.875, p=0.000), severe dental crowding
(58.2%, 2=110.151, p=0.000) and also to the
Angle class I (68.7%, 2=16.546, p=0.001).
The corrective treatment was specific to
ages between 9-12 years (49.6%, 2=63.993,
p=0.000), to late mixed dentition (38.2%) and
to permanent dentition (43.2% 2=63.369,
p=0.000), to moderate dental crowding (57.3%,
2=29.846, p=0.000) and to Angle class I (66.9%,
2=47.035, p=0.000).
Maxillary expansion was specific to ages
between 9-12 years (63.8%, 2=171.675, p=0.000),
to late mixed dentition (62.8%, 2=268.949,
p=0.000), mild (54.3%) and moderate (44.7%,
2=128.368, p=0.000) dental crowding, to Angle I
(56.9%) and II (33.5%, 2=13.740, p=0.000) classes.
The orthodontic extraction of permanent
teeth was specific to ages<12 years (67.1%,
2=171.675, p=0.000), to permanent dentition
(93.8%, 2=268.949, p=0.000), to moderate
(79.5%) and severe (20.5%, 2=128.368, p=0.000)
dental crowding, to Angle I (74.0%) and II
(24.0%, 2=13.740, p=0.003) classes (table 2).

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 NECESSITY FACTORS AND PREDICTORS OF DENTAL CROWDING TREATMENT

Table 2. Necessity factors for dental crowding treatment

Cross-tabulations, Chi-square tests

n=422 Interceptive Corrective Maxillary Extractions
treatment treatment expansion teeth
n 39 72 62 0
>9 years
% 58.2 18.3 33.0 0.0
Age intervals

n 28 195 120 48
9-12 years
% 41.8 49.6 63.8 32.9
n 0 126 6 98
<12 years
% 0.0 32.1 3.2 67.1
2 68.478 63.993 171.675 171.675
p 0.000 0.000 0.000 0.000
n 39 73 62 1
Early mixed
% 58.2 18.6 33.0 0.7
Dentition types

n 28 150 118 8
Late mixed
% 41.8 38.2 62.8 5.5
n 0 170 8 137
Permanent
% 0.0 43.2 4.3 93.8
2
75.875 63.369 268.949 268.949
p 0.000 0.000 0.000 0.000
n 25 98 102 0
Mild
% 37.3 24.9 54.3 0.0
Dental crowding

n 3 225 84 116
Moderate
% 4.5 57.3 44.7 79.5
n 39 70 2 30
Severe
% 58.2 17.8 1.1 20.5
2 110.151 29.846 128.368 128.368
p 0.000 0.000 0.000 0.000
n 46 263 107 108
Class I
% 68.7 66.9 56.9 74.0
n 12 108 63 35
Angle Class

Class II
% 17.9 27.5 33.5 24.0
Class III n 9 22 18 3
% 13.4 5.6 9.6 2.0
2 16.546 47.035 13.740 13.740
p 0.001 0.000 0.000 0.003

International Journal of Medical Dentistry 203

Georgeta ZEGAN, Cristina Gena DASCLU, Radu Bogdan MAVRU, Daniela ANISTOROAEI

The model of binary logistic regression
permitted identification of the significant
predictive factors for the interceptive orthodontic
treatment (mild and moderate crowding and
maxillary expansion), with a precision of 92.4%
(test HL, p=0.410); for the corrective orthodontic
treatment (local factors, maxillary expansion and
orthodontic extraction) with a precision of
95.3% (test HL, p=0.618); for the surgical-
orthodontic treatment (mild and moderate
crowding and orthodontic extraction), with a
precision of 91.5% (test HL, p=0.306) (table 3).

Tabel 3 Binary logistic regression analysis of predictive factors

95% Confidence
Wald p interval for OR
Parameters B OR
statistic value
Lower Upper
Interceptive orthodontic treatment
Mild crowding -1.366 18.052 0.000 0.255 0.136 0.479
Moderate crowding -4.370 48.913 0.000 0.013 0.004 0.043
Maxillary expansion 2.643 23.438 0.000 14.060 4.822 40.995
Corrective orthodontic treatment
Local causes -2.125 10.504 0.001 0.119 0.033 0.432
Maxillary expansion -1.053 5.070 0.024 0.349 0.140 0.873
Orthodontic extraction -3.702 16.842 0.000 0.025 0.004 0.145
Surgical-orthodontic treatment
Mild crowding -2.699 11.668 0.001 0.067 0.014 0.317
Moderate crowding -1.036 4.073 0.044 0.355 0.130 0.971
Orthodontic extraction -5.112 152.738 0.000 0.006 0.003 0.014

4. DISCUSSION patients, detection of dental crowding occurred

The present research was performed on a
group of patients suffering from various clinical
forms of dental crowding, treated orthodontically,
by evaluating their age intervals and type of
dentition in the moment of its detection, the
Angle classes of diagnosis, the associated
anomalies, the etiological causes and types of
therapeutical needs, in order to find the
statistically significant necessity and predictive
factors of the treatment.
For avoiding any possible statistical error,
patients with the same characteristics have been
selected. The multiple variables resulting from
the characteristics of the experimental group
were employed in the study. The effects under
investigation were based on the statistically
significant relations established with the age,
dentition, cause, effect and therapy applied to
patients. Considering the mean age of the
during late mixed dentition and the permanent
young one, for both sexes. If identified in early
mixed dentition, dental crowding may be solved
by means of conservative techniques and with
minimum dental costs [13,14]; however, when
identified in adolescent patients, the type of
intervention is different and more complex, both
orthodontically and surgically [15,16]. Most of
the cases were represented by moderate dental
crowding, included in Angle I malocclusion
class, associated with crossbite, induced by local
causes.
The chi-square test identified the necessity
factors for the interceptive orthodontic (age >9
years, early mixed dentition, severe dental
crowding from Angle I class) and corrective
treatment (age between 9-12 years, late mixed
dentition, permanent dentition, moderate dental
crowding from Angle I class) and for maxillary
expansion (age between 9-12 years, late mixed

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 NECESSITY FACTORS AND PREDICTORS OF DENTAL CROWDING TREATMENT
dentition, mild and moderate dental crowding
from Angle I and II classes) and extraction of
permanent teeth for orthodontic reasons (age
<12 years, permanent dentition, moderate and
severe dental crowding from Angle I and II
classes).
The model of binary logistic regression applied
identified the predictive factors for the types of
orthodontic treatment, according to the nature of
the intervention. The recommendation for mild
and moderate dental crowdings was maxillary
expansion, as a predictive factor of the interceptive
orthodontic treatment. For dental crowding with
local causes, maxillary expansion and orthodontic
extraction - as predictive factors of the corrective
orthodontic treatment - were indicated. Finally,
for mild and moderate crowdings, orthodontic
extraction as a predictive factor of the surgical-
orthodontic treatment was recommended.
All these predictive factors had not been
identified up to now, the existing studies having
discussed only some unilateral aspects of this
disease [1720].
5. CONCLUSIONS
The conclusion of the present study is that the
mean age at which dental crowding was detected
was an advanced one, the highest frequency
being registered for moderate crowding of Angle
I class, with local causes, associated with
crossbite. The necessity and predictive factors of
treatment were adapted to age, dentition, severity
of crowding and Angle class of malocclusion.
The study suggests the need to involve dentists
in the early detection of this common dental
anomaly, for preventing subsequent
complications. Similar further studies should be
extended to other types of malocclusions, known
as affecting both the health condition and dental
aesthetics of the population.
Acknowledgements
This work received financial support through
the Program of Excellence in Multidisciplinary
Doctoral and Postdoctoral Research in Chronic
Diseases, contract no. POSDRU / 159 / 1.5 / S
/ 133377, the beneficiary being The University of
Medicine and Pharmacy, U.M.F. Gr. T. Popa
International Journal of Medical Dentistry
of Iassy, receiving funds from the European
Social Fund through the Sectoral Operational
Programme Human Resources Development
2007-2013.
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