C. Grippaudo*, F. Pantanali*, E.G.

Paolantonio*, M.E. Grecolini*, R. Saulle**, G. La

Torre**, R. Deli*

Keywords Malocclusion; Treatment needs.

*Postgraduate School in Orthodontics

Universit Cattolica del Sacro Cuore, Rome, Italy
**Department of Public Health and Infectious Diseases
Sapienza University of Rome, Rome, Italy
e-mail: cgrippaudo @ rm.unicat t.it

Prevalence
of malocclusion
in Italian
schoolchildren and
orthodontic treatment
need
abstrac
t
Aim The aim of the study was to estimate the prevalence
of malocclusion and the need for orthodontic treatment
in a sample of 3,017 Italian schoolchildren.
Materials and methods Study design: 1,375
males and 1,642 females, aged between 8 and 13
years, were visited in primary and secondary schools.
Signs of malocclusion were registered according to an
occlusal index by trained and calibrated operators. First
the prevalence of malocclusion was calculated in
accordance to a scale of need for orthodontic
treatment (R.O.M.A. index), which considers both
malocclusion signs and risk factors for worsening of
malocclusion without any treatment and
during
craniofacial development. Then the distribution of the
most frequent characteristics, signs and symptoms was
evaluated both within each risk grade and in the basic
sample.
Results The overall percentage of children
classified as 3, 4 and 5 grade accounted for 75.8% of
the sample. The percentage of children classified as 4
and 5 grade are similar to those found in other
European countries. The most frequent features found
are poor oral hygiene, caries and early loss of
deciduous teeth, deviation from full intercuspation,
increased overbite and overjet. Conclusion This
epidemiological research describes the current
orthodontic treatment need in Italy in children
with a late mixed dentition.

EuropEan Journal

of

paEdiatric dEntistry

vol.

14/4-2013

58

the need for orthodontic treatment in a sample of

3,017 school children aged 8-13 in Italy.

Introduction
Occlusal indices are used to rank malocclusion and
identify the individuals in special need for orthodontic
treatment, on the grounds of the potential damages
malocclusion might cause [Taylor, 1993]. They are
introduced
to
minimise
the
subjective
component of diagnosis and assessment of the
malocclusion. Some indices are used also to assess
the outcome of orthodontic treatment [BorzabadiFarahani, 2011]. They have been used successfully
in many countries and have provided useful
information on treatment need and provision of
orthodontic
services
[Espeland et al., 1992;
Richmond, 1993; Richmond and Andrews,
1993; Birkeland et al., 1996].
In countries of Northern and Central Europe
(Switzerland,
England,
Germany,
France,
Belgium) a great number of surveys have been
produced [Josefsson et al., 2007; Chestnutt et al.,
2006; Tausche et al., 2004; Souames et al., 2006;
Willems et al., 2001; Grabowski et al., 2007], whereas
there are few studies about
the prevalence of
malocclusions and orthodontic treatment need in
Southern European countries [Perillo et al., 2010]. In
Italy, in the last decades, several studies have been
undertaken to report the oral health status in children
and adolescents [Angelillo et al., 1990-99], but very
few focused on assessment of the prevalence of
malocclusion and orthodontic treatment need
[Ciuffolo et al., 2005; Nobile et al., 2007]. Occlusal
indices have been criticised for not being easy to use,
as they require long time, complicated calculations and
qualified staff for data collection [Tang and Wei,
1993], lack of items about skeletal problems, and
seem appropriate in permanent dentition and in
examining patients whose growth
is
already
complete,
rather
than
across all age ranges.
However, in young patients orthodontic problems are
not
restricted to dental disorders, being often
accompanied by altered underlying skeletal
relationships and closely related to craniofacial growth
and development. That is why the age and stage of
development of the patient entail different degrees of
risk of malocclusion, accompanied by negative effects
on the masticatory function. The R.O.M.A. index (Risk
Of Malocclusion Assessment index) [Russo et al.,
1998] is a tool to assess treatment need in young
patients and has been previously validated [Grippaudo
et al., 2007]. Unlike other indices, the R.O.M.A. index
(Table 1) was specifically devised for use for young
patients, in an attempt to rate not only the dental
malocclusion, but also skeletal and functional aspects,
which in children are determinants of the orofacial
development.
The aim of this investigation, which follows an
earlier
study
performed on
420
children
[Grippaudo et al., 2007], is to use the R.O.M.A.
index to estimate the prevalence of malocclusion and
EuropEan Journal

of

paEdiatric dEntistry

vol.

14/4-2013

59

EpidEmiology of malocclusion in italy

GRADE 5
Systemic problems
Malformation syndromes

5a

Congenital malformations

5b

Postural or orthopaedic problems

4c

Medic or auxological problems

4d

Genetic problems of the jaws

4e

Facial or mandibular asymmetries

4f

TMJ dysfunctions

4g

Sequelae of trauma or surgery of the cranio-facial district

OVJ<0 mm (maxillary hypodevelopment or mandibular
hyperdevelopment)
OVJ>6 mm (maxillary hyperdevelopment or mandibular
hypodevelopment)
Mandibular hypo- or hyperdivergence

4j
4k

Scissor bite

4m

Anterior or posterior crossbite >2 mm

Displacement < 4 mm

4n
4o

Open bite > 4 mm

Hypodentia of permanent teeth

4p
4q

OVJ>0 mm (maxillary hypodevelopment or mandibular

hyperdevelopment)
3 mm <OVJ> 6 mm (maxillary hyperdevelopment or mandibular
hypodevelopment)

3k

Caries and early loss of deciduous teeth

3l

Anterior or posterior crossbite >1 mm

Displacement >2 mm

3n
3o

Open bite > 2 mm

Overbite > 5mm

3p
3r

0 mm <OVJ> 3 mm (maxillary hyperdevelopment or mandibular

hypodevelopment)

2h

Anterior or posterior crossbite <1 mm

Displacement >1 mm

2n
2o

Open bite > 1 mm

Anomalies of the tooth eruption sequence

2p
2s

Poor oral hygiene

Deviation from full interdigitation (up to a cuspid)

2t
2u

Functional asymmetries

2v

Bad habits
Mouth breathing

2w
2x

GRADE 4
Systemic problems

Craniofacial problems

4h
4i

Dental problems

GRADE 3
Craniofacial problems

3h

Dental problems

GRADE 2
Craniofacial problems

Dental problems

Functional problems

GRADE 1
None of the problems listed above

tabLE 1 The R.O.M.A. index.

EuropEan Journal

of

paEdiatric dEntistry

vol.

14/4-2013

60

grippaudo C. et al.

Materials and methods

The investigation was planned as a crosssectional study and the R.O.M.A. Index was used in
examining
3017 Italian children. The sample was balanced
according to
gender,
age
and
geographical
distribution (from North, Center and South of Italy).
It consisted of 1375 males (45,6%) and 1642 females
(54,4%) aged between
8 and 13 years (Table 2) who have been visited
between
2009 and 2011 in primary and secondary schools of
the following Italian regions: Piedmont and Friuli
(North), Abruzzo and Lazio (Center), Puglia and
Calabria (South). The R.O.M.A. index was applied by
operators who had previously underwent a training
period of one month following the instructions of a
special manual, in order to apply the index with the
same standard of judgment and to minimise errors. In
addition, the index had been already validated and its
intra-examiner and inter- examiner reproducibility
verified [Grippaudo et al., 2007]. To evaluate the
reproducibility, the
intra-examiner error was
calculated on the tables index made by the same
operator who examined 20 children twice, one
month apart. A second operator independently
collected a third table index for each of the 20 children
to assess the inter- examiner error. The Kappa values
were between 0.643 and 1.00 for the intra-operator
concordance (0.00 < p
< 0.002), and between 0.773 and 1.00 for the interoperator concordance (p = 0 < 0.001): the index is
therefore highly reproducible. The patient sample was
large enough for an epidemiological study. Data
were collected
about
age,
gender
and
geographical area, towns or villages in Northern,
Central and Southern Italy. The purpose was to
avoid bias and to obtain a true picture of
malocclusion problems affecting Italian children. After
calculating the prevalence of malocclusion on the basis
of the degree of orthodontic risk determined by the
index, we evaluated the distribution of the most
frequent characteristics, signs and symptoms both
within each risk grade and in the basic sample.

AGE

NORTH

CENTER

SOUTH

487

16.14

153

156

178

547

18.13

225

147

175

10

495

16.41

192

135

168

11

579

19.19

224

138

217

12

490

16.24

185

138

167

13

419

13.89

147

129

143

TOT

3017

100

1126

843

1048

tabLE 2 Study sample.

Results
The main index items found were poor oral hygiene
(2t), caries and early loss of deciduous teeth (3l),
deviation from full intercuspation (2u), increased
overbite (3r) and increased overjet which has an
overall prevalence of
33.1% considering all the items for overjet (4h, 3h,
2h) (Fig. 1). The prevalence of each item was calculated
for each grade index.

Grade 2
There was
a considerable frequency
problems relating to oral hygiene, bad habits
displacement in grade 2 of the index in addition
fair percentage of cases with increased overjet up
mm (Fig. 2). However these
problems
do
necessarily imply dentoskeletal disharmony.

Grade 3
The main problems for grade 3 (Fig. 3) were
displacement greater
than
2 mm (3o) and
overbite greater than 5 mm (3r). There was also a
high rate of caries with early loss of deciduous teeth
(3l), overjet up to 6 mm (3h), anterior or posterior
crossbite up to 2 mm (3n), Class III malocclusion
without reverse overjet (3k).

35

35

32.1%

32.1%

30

30

25

25
20.8%

13.5%

20
%

%
15

20.8%

19.2%

20
14.6%

15

13%

15.5%

13.5%

13.2%

12%

9.2%

10

10
6.6%

4.9%

2.6%

3.2%

2.4%

0
2h

2t

2u

3h

3l

3n

3r

4h

of
and
to a
to 3
not

2h

2n

2o

2p

2s

2t

2u

2v

2w

2x

fig. 1 Characteristics of the most frequent malocclusions in

the sample (%).

316

fig. 2 Distribution of the characteristics of risk grade 2 in the

basic sample (%).

EuropEan Journal

of

paEdiatric dEntistry

vol.

14/4-2013

EpidEmiology of malocclusion in italy

30
25.5%
25

19.2%

20

14.6%
15

13%
9.2%

10
7%
5

3.4%

0
3k

3h

3l

3n

3o

3p

3r

fig. 3 Distribution of the characteristics of risk grade 3 in

the basic sample (%).

Grade 4
The most frequent occlusal problems for grade 4
(Fig.
4) were displacement greater than 4 mm (4o),
maxillary
hyperdevelopment/mandibular
hypodevelopment with overjet greater than 6 mm (4h)
and anterior or posterior crossbite greater than 2 mm
(4n), while the prevalence of Class III malocclusion with
reverse overjet was low (4k).
It is quite remarkable that 37.7% of the examined
children were classified as at moderate need,
as defined by grade 3 of the index (non-severe
alterations in dental and /or skeletal relationships,
which
persist and often worsen with growth).
Significantly, 37.8% of subjects fell within grade 4 of
the
index (great need), presenting greater
craniofacial skeletal malformations and occlusal
alterations, often in association with systemic or
growth disorders which likely worsen the prognosis
(Fig. 5). Only 0.3% of children is in grade 5
of treatment need
(extreme need) for the
presence of underlying systemic conditions or
congenital malformations. Therefore, the overall
percentage of children with moderate, great and
extreme degree of the index accounted for 75.8% of
the sample.

Discussion
The results of this study showed that 38.16% of the
examined children have extreme and great degree of
orthodontic treatment need and the percentage
rises to 75.8 when including also the grade 3
(moderate degree). These findings should be taken
into great account
in devising strategies to
improve patient service quality in public and private
settings and also in planning preventive measures.
Deep overbite and increased overjet showed high
frequency as well as displacement. Anterior and
posterior crossbite was frequently found in degrees
of risk moderate and great. Also in other studies

fig. 4 Distribution of the characteristics of risk grade 4 in the

basic sample (%).

overjet, deep bite and posterior crossbite were the

most common malocclusions found in mixed dentition
[Kerosuo, 1990; Tschill et al., 1997; Chevitarese et
al.,
2002; Grabowski et al., 2007].

37.8%
n. 1141

37.7%
n. 1136

13.5%
n. 407

10.7%
n. 323

fig. 5
Distribution
of risk
grades in
the basic
sample.

0.3%
n. 10

PREVALENCE
AUTHORS
OF
ORTHODONTIC
TREATMENT
NEED

COUNTRY

32,7%

BROOK and SHAW, 1989

UK

33%

BURDEN and HOLMES, 1994

UK

35%

CHESTNUTT et al., 2006

UK

39,5%

JOSEFSSON et al., 2007

Sweden

21,6%

MIGALE et al., 2009

Italy

21,3%

SOUAMES et al., 2006

France

21,8%

MANZANERA et al., 2009

Spain

27,3%

PERILLO et al., 2010

Italy

tabLE 3 Prevalence of malocclusion in previous European

studies.

EuropEan Journal

of

paEdiatric dEntistry

vol.

14/4-2013

317

grippaudo C. et al.

The orthodontic features of the population have

been the object of several investigations in different
European countries with the purpose of recording
the prevalence of malocclusions and evaluating
orthodontic treatment needs. According to the present
research, 38.16% of the whole sample was
classified as risk grades 4 and 5, or being in need of
orthodontic treatment. The results show that the
prevalence is in line to that found in previous British
and Swedish studies conducted on similar target
populations, but higher than that found in other
studies conducted in Italy, France and Spain [Brook
and Shaw, 1989; Burden and
Holmes,
1994;
Chestnutt et al.,
2006; Souames et al., 2006;
Josefsson et al., 2007; Migale et al., 2009; Manzanera
et al., 2009; Perillo et al., 2010] (Table 3).
The present study indicates that 75.8% of the
sample has malocclusion with moderate, great or
extreme risk of worsening. These data can be useful for
management and planning of orthodontic treatment
within public health settings: the observation of a
large number of child patients with major orthodontic
problems indicates that intervention is often needed
before the end of dental occlusion development.

Conclusion
Current epidemiological data are needed to
detect trends or determine changes in the prevalence
of malocclusion for proper screening and treatment
planning services in the country. The overall prevalence
of children in need of orthodontic treatment in Italy
evaluated with the R.O.M.A. index was 75.8%. We
believe that this result is important for the sample
size. Moreover the sample is equally balanced for age,
sex and geographical origin and it is representative of
Italian children. A prevalence of orthodontic treatment
need of 75.8% suggest the need to develop screening
programmes and appropriate levels of health care in
orthodontics. It is also important that 32.1% of the
sample has poor oral hygiene (2t) and
14.6% is affected
by caries with early loss of
deciduous teeth (3l). For these reasons it should be
intensified preventive and health care programmes in
pediatric dentistry and in orthodontics and raise
awareness among parents, pediatricians and general
practitioners.

References
Abu Alhaija E S, Al-Khateeb S N, Al-Nimri K S 2005 Prevalence of
malocclusion in 13-15 year-old North Jordanian school children.
Community Dental Health 22(4): 266-271
Angelillo I F, Torre I, Nobile C G A, Villari P 1999 Caries and fluorosis
prevalence in communities with different concentration of fluoride in the
water. Caries Research 33: 114-122
Angelillo I F, Sagliocco G, Hendricks S J H, Villari P 1990 Tooth loss
and dental caries in institutionalized elderly in Italy. Community Dentistry
and Oral Epidemiology 18: 216-218
Angelillo I F, Nobile C G A, Pavia M 1996 Oral health status and
treatment needs in immigrants and refugees in Italy. European Journal of
Epidemiology

12: 359-365
Birkeland K, Be O E, Wisth P J 1996 Orthodontic concern among 11-yearold children and their parents compared with orthodontic treatment need
assessed by Index of Orthodontic Treatment Need. American Journal of
Orthodontics and Dentofacial Orthopedics 110: 197-205
Borzabadi-Farahani A 2011 An insight into four orthodontic treatment
need
indices. Progress in Orthodontics 12(2): 132-142
Brook P H, Shaw W C 1989 The development of an index of orthodontic
treatment priority. European Journal of Orthodontics 11: 309-320
Burden D J, Holmes A 1994 The need for orthodontic treatment in the child
population of the United Kingdom. European Journal of Orthodontics 1:
395-399
Chestnutt I G, Burden D J, Steele J P, Pitts N B, Nuttall N M, Morris A J
2006
The orthodontic condition of children in the United Kingdom, 2003. British
Dental Journal 200: 609-612
Chevitarese A B, Della-Valle D, Moreira T C 2002 Prevalence of
malocclusion
in 46 year old Brazilian children. Journal of Clinical Pediatric Dentistry 27:
81-85
Ciuffolo F, Manzoli L, D'Attilio M, Tecco S, Muratore F, Festa F, Romano
F 2005 Prevalence and distribution by gender of occlusal characteristics
in a sample of Italian secondary school students: a cross-sectional study.
European Journal of Orthodontics 27(6): 601-606
Espeland L V, Ivarsson K, Stenvik A 1992 A new Norwegian index
of
orthodontic treatment need related to orthodontic concern among 11-yearolds and their parents. Community Dentistry and Oral Epidemiology 5: 274279
Grabowski R, Stahl F, Gaebel M, Kundt G 2007 Relationship between
occlusal findings and orofacial myofunctional status in primary and mixed
dentition. Journal of Orofacial Orthopedics 68: 26-37
Grippaudo C, Paolantonio E G, Deli R, La Torre G 2007 Validation of the
Risk Of Malocclusion Assessment (ROMA) Index European Journal of
Paediatric Dentistry 3(8): 136-142
Grippaudo C, Paolantonio E G, Deli R, La Torre G 2008 Orthodontic
treatment need in the Italian child population. European Journal of
Paediatric Dentistry 9(2): 71-75
Josefsson E, Bjerklin K, Lindsten R 2007 Malocclusion frequency in Swedish
and immigrant adolescents - influence of origin on orthodontic treatment
need. European Journal of Orthodontics 29: 79-87
Kerosuo H 1990 Occlusion in the primary and early mixed dentitions in
a group of Tanzanian and Finnish children. ASDC Journal of Dentistry for
Children 57: 293-298
Manzanera D, Montiel-Company J M, Almerich-Silla J M, Ganda J L 2009
Orthodontic treatment need in Spanish schoolchildren: an epidemiological
study using the Index of Orthodontic Treatment Need. European Journal of
Orthodontics 31(2): 180-183
Migale D, Barbato E, Boss M, Ferro R, Ottolenghi L 2009 Oral health
and malocclusion in 10-to11 years-old children in southern Italy. European
Journal of Paediatric Dentistry 10(1): 13-18
Nobile C G, Pavia M, Fortunato L, Angelilo I F 2007 Prevalence and factors
related to malocclusion and orthodontic treatment need in children and
adolescents in Italy. European Journal of Public Health 17: 637-641
Perillo L , Masucci C , Ferro F , Apicella D, Baccetti T 2010 Prevalence of
orthodontic treatment need in southern Italian schoolchildren. European
Journal of Orthodontics 32: 49-53
Richmond S 1993 Personal audit in orthodontics. British Journal of
Orthodontics 20: 131-140
Richmond S, Andrews M 1993 Orthodontic treatment standards in Norway.
European Journal of Orthodontics 15: 7-15
Russo E, Grippaudo C, Marchionni P, Deli R 1998 Il ROMA index come
metronomo della terapia ortodontica nel paziente in crescita. Proceedings
National Congress of SIDO, Firenze, 28-31 oct. 1998
Souames M, Bassigny F, Zenati N, Riordan P J, Boy-Lefevre M L 2006
Orthodontic treatment need in French schoolchildren: an epidemiological
study using the Index of Orthodontic Treatment Need. European Journal of
Orthodontics 28: 605-609
Tang E L K, Wei S H Y 1993 Recording and measuring malocclusion: a
review of the literature. American Journal of Orthodontics and Dentofacial
Orthopedics 103: 344-350
Tausche E, Luck O, Harzer W 2004 Prevalence of malocclusions in the
early
mixed dentition and orthodontic treatment need. European Journal of
Orthodontics 26: 237-244
Taylor N G 1993 Orthodontic in the Netherlands. British Dental Journal 23:
333-335
Tschill P, Bacon W, Sonko A 1997 Malocclusion in the deciduous dentition
of Caucasian children. European Journal of Orthodontics 19: 361-367

318

EuropEan Journal

of

paEdiatric dEntistry

vol.

14/4-2013