Associations between Sagittal, Transversal, and Vertical Planes with Dental Anomalies in Pretreatment Orthodontic Patients of Kosovo

Keywords

malocclusion - dental anomalies - crowding - crossbite - sagittal plane - transversal plane

Introduction

Malocclusions have negative effects on emotional and social well-being.[1] According to the World Health Organization, malocclusion is one of the most important oral health problems, after caries and periodontal disease. The prevalence range is extensive and heterogeneous.[2] There is a higher frequency of dental anomalies among orthodontic patients because some of the dental anomalies can play a role in the development of malocclusion. Impactions and supernumerary teeth are the main dental anomalies among the studied orthodontic patients.[3]

Malocclusion has a multifactorial etiology, being caused by hereditary factors, quality of life, environmental factors, or a combination of these factors.[2] [4] Genetically determined factors influence growth and can, therefore, lead to malocclusion. These influences can be combined with etiological factors such as thumb sucking. When the child interposes his thumb between the dental arches, it causes the tongue to move downwards. The tongue does not reach its correct position on the palate, preventing it from developing transversely.[2] Among the various classes of malocclusion, class II division 2 has displayed a significant association with dental anomalies.[5]

Despite the high frequency of dental anomalies among orthodontic patients, these factors are often unacknowledged in clinical orthodontic diagnosis and treatment planning. So to improve public oral health, it is vital to determine the association of malocclusion and dental anomalies and help pursue the orthodontic treatment.[6] [7] Understanding the comparisons and correlations of malocclusion with anomalies will provide ways for new research, treatment plans, and management of patients.[6]

Although several studies have examined the prevalence and classification of malocclusion, data are not sufficient. The comprehensive correlations of malocclusions with dental anomalies such as hypodontia, ectopic eruption, and crossbites were deficient. Moreover, very limited data are available on the prevalence of malocclusion and associated dental anomalies in the Kosovan population. To date, no study has evaluated the distribution of malocclusion types across all three spatial planes, while simultaneously assessing their association with common dental anomalies in orthodontic patients in Kosovo.

The correlations between the three classes of malocclusion and dental anomalies have not been investigated in the Kosovan population; hence, the aim of the current study was to correlate the existence of dental anomalies with different types of malocclusions as the occurrence of anomalies is common in malocclusion.

Materials and Methods

This retrospective cross-sectional study was performed among 617 patients distributed among two age groups: below and above 18 years visiting the orthodontic specialty clinics in Kosovo. Data for the study were taken from the pretreatment diagnostic records of patients from 2017 to 2023. The following inclusion criteria were incorporated: archived files, no significant medical and dental history, no extensive restorations that can hinder the identification of dental anomalies, no previous history of orthodontic treatment, Albanian patients from Kosovo, and complete dental files including history, examination, orthopantomogram, and photographs. The exclusion criteria were maxillofacial trauma, oral pathologies, and diagnosed syndromes. The following occlusal relationships (regarding Angle's classification) were assessed during the examination of study casts: molar and canine sagittal relationships and coincidence of incisal midlines. Angle's classification was considered, and the findings were categorized into class I, II, and III malocclusion groups. Patients' study models, dental files, and dental radiographs were investigated to identify the following dental anomalies: any congenitally missing teeth except third molars (hypodontia), impaction (tooth that remains unerupted after complete root development), ectopic eruption (tooth erupting in a different position than usual), and diastema (space between maxillary central incisors). Moreover, malocclusion in the transverse plane (upper and lower midline, anterior and posterior crossbite), malocclusion in the vertical plane (a deep bite, an open bite), and anterior and posterior crowding in both jaws were also examined. One operator made all the investigations, and then they were rechecked by another orthodontic expert.

Data analysis was done by SPSS 16.0 software (SPSS Inc., Chicago, Illinois, United States). Descriptive statistics, along with frequency and prevalence, were performed. The chi-squared test was used to investigate whether the distribution of the patients with dental anomalies differed between the three classes of malocclusion. The level of significance for each comparison was calculated using the Bonferroni correction. The level of chi-squared test significance was set at p < 0.05.

Results

The results focus on the gender-based analysis and the associations of dental planes with specific dental conditions. [Table 1] shows the distribution of dental characteristics by gender reveals. The distribution of dental characteristics by gender and age shows that a higher percentage of individuals over 18 years old are present in both females (83.6%) and males (81.3%), compared with those 18 and younger (16.4% females, 18.8% males).

Table 1 Distribution of dental characteristics by gender

Age	Female		Male		Total
	N	%	N	%	N	%
≤ 18	62	16.4	45	18.8	107	17.34
> 18	315	83.6	195	81.3	510	82.66
Association in sagittal plane	N	%	N	%	N	%
Class I	172	45.6	103	42.9	275	44.57
Class II	143	37.9	83	34.6	226	36.63
Class III	62	16.4	54	22.5	116	18.80
Associations in transversal plane
Associations in transversal plane – Upper mid
Right	36	9.5	16	6.7	52	66.67
Left	17	4.5	9	3.8	26	33.33
Associations in transversal plane – Lower mid
Right	9	2.4	9	3.8	18	38.30
Left	17	4.5	12	5.0	29	61.70
Associations in transversal plane – Anterior crossbite
Yes	56	14.9	45	18.8	101	16.37
No	321	85.2	195	81.3	516	83.63
Associations in transversal plane – Posterior crossbite
Yes	64	17.0	37	15.4	101	16.37
No	313	83.0	203	84.6	516	83.63
Association in vertical plane
Association in vertical plane – Deep bite
Yes	114	30.2	76	31.7	190	30.79
No	263	69.8	164	68.3	427	69.21
Association in vertical plane – Open bite
Yes	60	15.9	28	11.7	88	14.26
No	317	84.1	212	88.3	529	85.74
Dental anomalies
Dental anomalies – Hypodontia
Yes	46	12.2	33	13.8	79	12.80
No	331	87.8	207	86.3	538	87.20
Dental anomalies – Ectopic
Yes	98	26.0	58	24.2	156	25.28
No	279	74.0	182	75.8	461	74.72
Dental anomalies – Impaction
Yes	47	12.5	33	13.8	80	12.97
No	330	87.5	207	86.3	537	87.03
Dental anomalies – Diastema
Divergent	8	2.1	4	1.7	12	1.94
Convergent	320	84.9	198	82.5	518	83.95
Parallel	49	13.0	38	15.8	87	14.10
Anterior crowding
Lower arch
Yes	221	58.6	119	49.6	340	55.11
No	156	41.4	121	50.4	277	44.89
Upper arch
Yes	208	55.2	135	56.3	343	56
No	169	44.8	105	43.8	274	44
Posterior crowding
Lower arch
Yes	51	13.5	44	18.3	95	15.40
No	326	86.5	196	81.7	522	84.60
Upper arch
Yes	43	11.4	33	13.8	76	12.32
No	334	88.6	207	86.3	541	87.68

In the sagittal plane, the majority of both females (45.6%) and males (42.9%) belong to class I. However, males have a higher proportion of class III (22.5%) compared with females (16.4).

In the transversal plane, the upper midline is predominantly on the right side for both genders, with females (9.5%) showing a higher percentage than males (6.7%). For the lower midline, both genders show a similar distribution, but a slightly higher percentage of males (5%) compared with females (4.5%) have the left side alignment. Regarding anterior crossbite, both genders exhibit a majority without the condition (85.2% of females and 81.3% of males), but more males (18.8%) have anterior crossbite than females (14.9%). A similar trend is observed in posterior crossbite, where males (15.4%) exhibit a slightly higher frequency compared with females (17%).

The vertical plane analysis indicates that deep bite is more common in males (31.7%) than females (30.2%), though the difference is minimal. In contrast, females have a slightly higher occurrence of open bite (15.9%) compared with males (11.7%).

Regarding dental anomalies, hypodontia affects a higher percentage of males (13.8%) compared with females (12.2%). In contrast, the distribution of ectopic and impaction anomalies is fairly balanced between genders, with a slightly higher prevalence in females. Finally, for crowding, both males and females exhibit similar trends, with a higher percentage of females experiencing anterior crowding in both the lower (58.6%) and upper arches (55.2%).

In the sagittal plane and upper midline (transversal plane), the distribution of upper midline alignment (right vs. left) across sagittal classes shows no significant association (Pearson's chi-square = 3.252, p-value = 0.197). While class I predominates in both the right (17) and left (14) midline positions, class II and class III show varying distributions, but none of these differences are statistically significant, as shown in [Table 2].

Table 2 Association of sagittal and transversal planes with dental conditions

Association in sagittal plane	Association in transversal plane – Upper mid
	Right		Left		Pearson's chi-square	p -Value
	N	%	N	%	3.252	0.197
Class I	17		14
Class II	24		8
Class III	11		4
	Association in transversal plane – Lower mid
Association in sagittal plane	Right		Left		Pearson's chi-square	p -Value
	N	%	N	%	2.833	0.243
Class I	10		9
Class II	6		14
Class III	2		6
Association in sagittal plane	Association in transversal plane – Anterior crossbite
	Yes		No		Pearson's chi-square	p -Value
	N	%	N	%	358.818	0.001
Class I	9		266
Class II	5		221
Class III	87		29
	Association in transversal plane – Posterior crossbite
Association in sagittal plane	Yes		No		Pearson's chi-square	p -Value
	N	%	N	%	16.569	0.001
Class I	42		233
Class II	52		174
Class III	7		109

Note: The level of chi-squared test significance was set at p < 0.05.

In the sagittal plane and lower midline (transversal plane), the lower midline alignment also reveals no significant association with the sagittal plane (Pearson's chi-square = 2.833, p-value = 0.243). Similar to the upper midline, class I and class II tend to be more balanced between right and left, with class III showing the least occurrence in both positions, as shown in [Table 2].

In the sagittal plane and anterior crossbite (transversal plane), significant association is observed between the sagittal plane and anterior crossbite (Pearson's chi-square = 358.818, p-value = 0.001). Class I has the highest occurrence of no anterior crossbite (266 cases), while class III shows a substantial shift, with 87 cases of anterior crossbite compared with only 29 cases without.

In the sagittal plane and posterior crossbite (transversal plane), a similar significant association is seen between the sagittal plane and posterior crossbite (Pearson's chi-square = 16.569, p-value = 0.001). The data presented in [Table 2] indicates that class I and class II have a higher percentage of no posterior crossbite, while class III has a greater percentage of posterior crossbite.

In vertical plane, significant association is found between the sagittal plane and deep bite (Pearson's chi-square = 147.523, p-value = 0.001). Class I malocclusion shows the highest frequency of no deep bite (225 cases), while class II also shows a substantial number of patients with deep bite (135 cases), and class III shows the least prevalence of deep bite (5 cases). [Table 3] indicates a clear correlation between class II malocclusion and the presence of deep bite, with class III showing the least occurrence. In vertical plane, the association between the sagittal plane and open bite is not statistically significant (Pearson's chi-square = 4.812, p-value = 0.090).

Table 3 Association of sagittal and vertical planes with bite conditions (deep bite and open bite analysis)

Association in sagittal plane	Association in vertical plane – Deep bite
	Yes		No		Pearson's chi-square	p -Value
	N	%	N	%	147.523	0.001
Class I	50		225
Class II	135		91
Class III	5		111
	Association in vertical plane – Open bite
Association in sagittal plane	Yes		No		Pearson's chi-square	p -Value
	N	%	N	%	4.812	0.090
Class I	31		244
Class II	41		185
Class III	16		100

[Table 4] shows that the association between the sagittal plane and hypodontia is not statistically significant (Pearson's chi-square = 0.330, p-value = 0.848). While the association between the sagittal plane and ectopic is marginally not significant (Pearson's chi-square = 4.261, p-value = 0.119), there is a noticeable trend where class I shows the highest frequency of ectopic eruptions (74 right-sided and 201 left-sided cases), followed by class II and class III.

Table 4 Association of sagittal plane with dental anomalies (hypodontia, ectopic, impaction, and diastema)

Association in sagittal plane	Dental anomalies – Hypodontia
	Yes		No		Pearson's chi-square	p -Value
	N	%	N	%	0.330	0.848
Class I	33		242
Class II	31		195
Class III	15		101
	Dental anomalies – Ectopic
Association in sagittal plane	Yes		No		Pearson's chi-square	p -Value
	N	%	N	%	4.261	0.119
Class I	74		201
Class II	47		179
Class III	35		81
Association in sagittal Plane	Dental anomalies – Impaction
	Yes		No		Pearson's chi-square	p -Value
	N	%	N	%	1.118	0.572
Class I	40		235
Class II	26		200
Class III	14		102

The association between the sagittal plane and impaction is also not statistically significant (Pearson's chi-square = 1.118, p-value = 0.572). The distribution of impaction in the sagittal classifications appears somewhat similar, with no distinct trend emerging across the groups as shown in [Table 4].

[Table 5] shows that the association between the sagittal plane and anterior crowding in the upper arch is statistically significant (Pearson's chi-square = 14.731, p-value = 0.001). Class I again shows the highest proportion of individuals with crowding (162 yes, 113 no), followed by class II (135 yes, 91 no) and class III (46 yes, 70 no). The significant p-value suggests that anterior crowding in the upper arch is strongly associated with the sagittal plane, with class I individuals being most affected.

Table 5 Association of sagittal plane with anterior crowding in upper and lower arches

Association in sagittal plane	Anterior crowding – Lower arch
	Yes		No		Pearson's chi-square	p -Value
	N	%	N	%	5.317	0.070
Class I	160		115
Class II	127		99
Class III	53		63
	Anterior crowding – Upper arch
Association in sagittal plane	Yes		No		Pearson's chi-square	p -Value
	N	%	N	%	14.731	0.001
Class I	162		113
Class II	135		91
Class III	46		70

[Table 6] shows that the association between the sagittal plane and posterior crowding in the lower arch is not statistically significant (Pearson's chi-square = 0.264, p-value = 0.876). The distribution of individuals with posterior crowding in the lower arch is similar across the sagittal classifications, with class I showing 41 yes and 234 no, class II with 37 yes and 189 no, and class III with 17 yes and 99 no.

Table 6 Association of sagittal plane with posterior crowding in upper and lower arches

Association in sagittal plane	Posterior crowding – Lower arch
	Yes		No		Pearson's chi-square	p -Value
	N	%	N	%	0.264	0.876
Class I	41		234
Class II	37		189
Class III	17		99
	Posterior crowding – Upper arch
Association in sagittal plane	Yes		No		Pearson's chi-square	p -Value
	N	%	N	%	0.353	0.838
Class I	32		243
Class II	28		198
Class III	16		100

Discussion

Extensive research on the prevalence and association of dental anomalies has been performed, but a specific focus on gender and age-based analysis and the relationship of dental planes with specific conditions remains limited. This study focuses on estimating how gender and age influence the distribution and correlation of dental characteristics across sagittal, transversal, and vertical planes. Gender-based comparative studies were included to understand biological differences, such as genetic and hormonal influences, that affect males and females differently.

Our findings demonstrated that there are some gender differences across various dental characteristics. The variations are mostly modest, with females showing slightly higher prevalence in anterior crowding, while males have higher occurrences of posterior crowding and certain anomalies like hypodontia and anterior crossbite.

It was noted in this study that there are more females in the ≤ 18 age group, while the > 18 group has a higher total representation in both genders. A review was done by De Ridder et al,[8] in which the prevalence of malocclusion and different orthodontic features in children and adolescents was reviewed.

Gender-based hormonal differences influence dental anomalies, with male hormones like growth hormones and insulin-like growth factor-1 playing a significant role. These hormones are directly related to structural development. Female hormones like estrogen and progesterone primarily affect gingival and periodontal tissues. A latest study in 2023[9] found 33% of children with growth hormone deficiency developed dental anomalies. Our findings suggest that the prevalence of dental anomalies can vary by gender and population.

The prevalence of class I, II, and III malocclusions were 51.9, 23.8, and 6.5%, respectively, with the anterior crossbite rate at 7.8% and posterior crossbite rate at 9.0%. The prevalence of malocclusion and orthodontic features varies significantly across studies due to inconsistent methodologies. In another study, highest form of malocclusion was class I followed by class II subdivision.[10] In our study, ectopic eruption was the most common dental anomaly, which is opposite to the study conducted in India where rotated teeth was the most common dental anomaly in pretreatment orthodontic patients and another study in Iran where hypodontia was the most common dental anomaly.[11] [12]

In exploring the association of sagittal and transversal planes with dental conditions, our study found no significant associations for both upper and lower midlines. Class I malocclusion was predominant in both the right and left midline positions; however, classes II and III showed diverse distributions with no statistical significance. Contrarily, a significant correlation was seen between the sagittal plane and anterior crossbite with class III malocclusion particularly associated with anterior crossbite. Similarly, a significant association was seen between the sagittal plane and posterior crossbite, where class III malocclusion showed a higher prevalence of posterior crossbite. These findings align with the study of Iodice et al,[13] which reports associations between posterior crossbite and asymmetries in mandibular growth and muscle activity.

According to our current study there is a significant association between sagittal classifications and deep bite malocclusion. Class I malocclusion showing the highest frequency of no deep bite, class II exhibiting a substantial number of patients with deep bite, and class III showing the least prevalence of deep bite. However, the association between sagittal classifications and open bite was not statistically significant. This is similar to the previous study of Rasol et al,[14] who stated that class II malocclusion was significantly associated with deep bite, while association of class III malocclusion with deep bite was less frequent. Moreover, Brown et al[15] reported that open bite malocclusion was not significantly associated with sagittal classification, supporting our data that open bite is not greatly influenced by sagittal classification.

This study revealed that the dental anomalies of hypodontia, ectopic eruption, impaction, and diastema occur independently of sagittal malocclusion types, as no statistically significant associations were seen between sagittal classifications and the dental anomalies. These findings are consistent with existing literature presented by the American Academy of Pediatric Dentistry's guidelines, which indicate that dental anomalies like hypodontia and ectopic eruption may occur among different malocclusion types.[16] They contrast with the findings of the research by Selmani et al,[17] which suggested an association between third molars and anterior segment crowding.

No statistically significant relationship was observed between the sagittal plane and anterior crowding in the lower arch. While class I shows the highest number of individuals with crowding followed by class II and class III, the p-value indicates that these differences are not statistically significant, revealing contrasting associations. In contrast, the association between the sagittal plane and anterior crowding in the upper arch was statistically significant. Class I had the highest crowding followed by class II and class III. The findings reveal that the anterior crowding in the upper arch is strongly associated with the sagittal plane, particularly in class I cases. The study of Yuvashree et al[18] aligns with our study revealing class I malocclusion exhibit highest prevalence, class II noted to be moderate, and class III showed less severe crowding.

Our findings suggest a uniform distribution of posterior crowding across class I, II, and III malocclusions. Somewhat similar study was done by Crossley et al,[19] who concluded that the size of the mandibular apical base was not related to maxillary or mandibular crowding.

Conclusion

Our study concluded that in Kosovo's population the dental characteristics, including malocclusions and anomalies, are influenced by a combination of factors rather than solely sagittal classifications. There was a significant association between sagittal planes and conditions such as anterior crossbite, posterior crossbite, and deep bite; however, anomalies like hypodontia, ectopic eruption, and diastema occurred independently of sagittal classifications. Anterior crowding in the upper arch demonstrated a significant relationship with sagittal planes, particularly in class I malocclusions, but posterior crowding showed no such association.

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