European Journal of Orthodontics, 2018, 1–8

doi:10.1093/ejo/cjy044

Original article

Aging of the normal occlusion†

Felicia Miranda1, Camila Massaro1, Guilherme Janson1,
Marcos Roberto de Freitas1, José Fernando Castanha Henriques1,
José Roberto Pereira Lauris2 and Daniela Garib1,3
Departments of 1Orthodontics and 2Public Health, Bauru Dental School and 3Department of Orthodontics, Hospital of
Rehabilitation of Craniofacial Anomalies, University of São Paulo, Brazil.

Correspondence to: Felicia Miranda, Department of Orthodontics, Bauru Dental School, University of São Paulo, Alameda
Octávio Pinheiro Brisolla 9–75, Bauru - SP, 17012-901, Brazil. E-mail: felicia-miranda@hotmail.com

This article is based on research submitted by Dr Felicia Miranda in partial fulfilment of the requirements for the degree of
†

MSc in Orthodontics at Bauru Dental School, University of São Paulo, Brazil.

Summary
Objectives:  The aim of this study was to evaluate the qualitative occlusal changes in individuals
with normal occlusion during a period of 47 years.
Materials and methods:  The sample comprised dental models of 20 subjects with normal occlusion
(8 males; 12 females) taken at 13.2  years (T1) and 60.9  years of age (T2). The occlusal features
were evaluated with the objective grading system (OGS) and with the six keys to normal occlusion
(SKNO). The subjects also answered a questionnaire on the aesthetic and occlusal self-perception at
T2. Comparisons from T1 to T2 were performed with paired t- and McNemar tests (P less than 0.05).
Results:  OGS analysis showed a significant improvement in the marginal ridge levelling and tooth
buccolingual inclination. There was a significant deterioration of the antero-posterior occlusal
relationship from T1 to T2. Subjects without tooth loss showed a dental alignment worsening
between time points. The marginal ridges, buccolingual inclination, and interproximal contacts
improved. The SKNO analysis showed a significant deterioration of the maxillary second molars
buccolingual inclination and an improvement of the maxillary second molar angulation. All
patients were satisfied with their smiles, and 60 per cent of the subjects had no complaints. Dental
crowding caused dissatisfaction in 35 per cent of the sample.
Limitations:  A limitation of this study was the high prevalence of tooth loss in the sample from T1
to T2. Only 30 per cent of the subjects had no tooth loss in T2.
Conclusions:  The aging process slightly deteriorates some occlusal features of individuals with
normal occlusion. However, most individuals were satisfied with their aesthetics and occlusal
comfort at the sixth decade of life.

Introduction of age (2). A previous study evaluating the long-term stability of den-
tal arch form in normal occlusion subjects from 13 to 31 years of
The dramatic increase of life expectancy in the populations stimu-
age found a tendency for a more rounded shape for the mandibular
lates the evaluation of occlusal aging (1). Maturational changes were
arch (3). A  decrease of the maxillary and mandibular intercanine
previously studied in nontreated population with normal occlusion.
widths and arch length was also found while the mandibular incisor
In a longitudinal study of normal occlusion maturation from 9 to
crowding increased (3).
20 years of age, decreases in the arch length and intercanine widths
From 21 to 28 years of age, a decrease in the arch perimeter and an
were found (2). On the other hand, overjet, overbite, and incisor
increase in incisor crowding and overbite were observed in Brazilian
irregularity increased from the early permanent dentition to 20 years

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 2 European Journal of Orthodontics, 2018
individuals with normal occlusion (4). A cross-sectional study evalu-
ated the occlusal changes from 5 to 31  years in Swedish normal
occlusion individuals (5). In both arches, the intercanine width con-
tinuously decreased from 16 to 31 years (5). A follow-up of Finnish
normal occlusion subjects from 7 to 32 years showed decreases in the
intercanine distance, maxillary intermolar width, overjet, and overbite
after 15 years of age (6). From 25 to 46 years of age, decreases in max-
illary and mandibular intercanine widths, a decrease in maxillary arch
length, and an increase in mandibular incisor crowding were reported
(7). A continuous decrease in maxillary and mandibular intercanine
distances from 13 to 45 years of age was also reported (8).
Although efforts were performed to quantitatively evaluate the
longitudinal changes in normal occlusion, no previous study evalu-
ated changes in the quality of occlusion with aging. The American
Board of Orthodontics (ABO) has developed the objective grading
system (OGS) to evaluate the quality of orthodontically treated
occlusions (9). The OGS is assessed by scores given to eight occlu-
sal traits. Arch alignment, marginal ridges, buccolingual inclination,
occlusal relationship, occlusal contacts, overjet, and interproximal
contacts are evaluated using dental models (9). The classic study by
Andrews (10) identified 6 frequent features in 120 individuals with
normal occlusion, which may be used as guidelines to assess the
quality of treated and nontreated occlusions.
Does time impair the occlusion quality? Is normal occlusion sta-
ble from adolescence to late adulthood? These questions need to be
elucidated for a better understanding of normal occlusion aging pro-
cess. Therefore, this study aimed to qualitatively assess changes of
normal occlusion from 13 to 60 years of age.
Materials and methods
This observational and longitudinal study was approved by an eth-
ical committee in research. Written patient consents were obtained.
Sample size calculation was based on preliminary statistics including
the first five patients of the sample. For a standard deviation of 13.07
points for the OGS and a minimum difference of 10 points to be
Figure 1.  Enrolment process.
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detected between time points, a sample of 15 patients was required
to provide a statistical power of 80 per cent with an α of 0.05.
A sample of dental models from 82 white subjects with normal
occlusion, obtained between 1967 and 1970, was selected from the
files of the department of orthodontics at a university (T1). The inclu-
sion criteria of normal occlusion were the following: (1) complete
permanent dentition, (2) Class I molar and canine relationships, (3)
absence of crossbites, (4) positive overjet and overbite (ranging from
2 to 4 mm), (5) well-balanced faces, and (6) a maximum 2 mm of
incisor crowding with no previous history of orthodontic treatment.
All subjects were targeted to be recalled during 2015 and 2016 (T2).
The exclusion criteria applied at T2 were the following: (1) his-
tory of orthodontic treatment and (2) complete or extensive tooth
loss (two or more teeth in each hemiarch). From the initial sample,
38 subjects were reached. Eleven subjects were not enrolled due to
refusal to participate (8) or due to complete tooth loss (3). Twenty-
seven patients were enrolled and seven were excluded because they
did not meet the eligibility criteria (Figure  1). Eight subjects had
died and 36 could not be found probably due to name changes after
marriage. From the 20 selected volunteers, 8 were males and 12
were females. The mean age at T1 and T2 was 13.2 and 60.8 years,
respectively. The mean follow-up period was 47.6 years.
Dental models were also obtained at T2. Both T1 and T2 dental
models were scanned with the 3Shape R700 3D© scanner (3Shape
A/S, Copenhagen, Denmark). Dental model evaluation was performed
using the OGS manually, at both time points (9). Seven out of the eight
criteria were used, excluding only the angulation criteria due to the
absence of panoramic radiographs. A metal gauge commercialized by
the ABO was used (9). Measurements were performed by one investi-
gator to ensure consistency. The investigator was initially trained for
the OGS. During the calibration process, 30 per cent of the sample
was manually measured using the ABO metal gauge and instructions.
For each parameter that deviated from normal, one or two points were
subtracted. A score zero indicated ideal alignment and occlusion. The
score magnitude for each patient indicated a relative deviation from
ideal. The critical score for the ABO clinical examination is 30 (9).
 F. Miranda et al.
In addition, scores were given to the presence of all six keys to
normal occlusion (SKNO) by visual inspection following the subject-
ive analysis proposed by Andrews (10). A score zero was given when
a key was present and a score one when absent or deficient (11).
All patients answered a written questionnaire with seven ques-
tions on their self-appraisal of occlusal function and aesthetics
(Figure 2).
Statistical analyses
One operator performed all measurements and repeated them in 50 per
cent of the sample at least 3 weeks later. OGS normal distribution was
confirmed using Kolmogorov–Smirnov tests. Intraexaminer reproduci-
bility was evaluated using intraclass correlation coefficients (ICCs) and
Bland–Altman method for OGS analysis. Therefore, changes between
time points were evaluated using paired t-tests. A  subgroup without
tooth loss was analysed separately using paired t-tests.
Intraexaminer reproducibility for the presence or absence of the
SKNO was evaluated using kappa coefficient. SKNO changes between
time points were evaluated using McNemar tests corrected for multiple
testing (Holm–Bonferroni method). Results were considered significant
at P less than 0.05. Descriptive statistics were used for the questionnaires.
Results
Objective grading system
ICCs varied from 0.71 to 0.98, showing good to excellent reprodu-
cibility of OGS measurements (12). The variable that showed the
lower ICC was the marginal ridges. The variable that showed the
greater ICC was the interproximal contacts.
The scores for marginal ridges and buccolingual inclination showed
significant decreases from T1 to T2, representing quality improvement
in these variables (Table 1). On the other hand, the score for occlusal
relationship significantly increased from T1 to T2, showing deterior-
ation over time. No significant changes between the time points were
found for alignment, overjet, interproximal, and occlusal contacts.
When evaluating only subjects without tooth losses, a significant
interphase difference from T1 to T2 was found only for the align-
ment, marginal ridges, buccolingual inclination, and interproximal
Figure 2.  Written questionnaire answered by the sample subjects at T2.
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3
contacts (Table  2). Alignment showed a significant deterioration
from T1 to T2 (Table 2). Marginal ridges, buccolingual inclination,
and interproximal contacts showed a quality improvement in sub-
jects without tooth loss (Table 2).
Six keys to normal occlusion
Intraexaminer reproducibility showed substantial to almost perfect
agreement with kappa values varying from 0.64 to 1.00.
Changes for key 1 (interarch relationship) were not significant
(Table  3). Only the maxillary second molars showed a significant
improvement of key 2 (clinical crown angulation) between time
points. Key 3 (clinical crown inclination) showed significant deteri-
oration for the maxillary second molars from T1 to T2, with fre-
quent buccal inclination observed at T2.
No significant changes were found for rotation, interproximal
contacts, and curve of Spee.
Tooth loss
Out of 20 individuals, 14 showed at least 1 permanent tooth loss at
T2. The mean number of tooth loss at 60 years of age was 2.1 teeth
per subject. In general, posterior teeth were most frequently absent
than anterior teeth (Figure 3). Tooth loss was more frequent in the
mandible compared to the maxilla. In addition, for a total of 42
missing teeth, only 11 were rehabilitated with implants/prosthesis.
Written questionnaires
When asked about the satisfaction with their smiles, all patients
answered that they were satisfied. The median grade chosen to evalu-
ate the smiles was 8. Grades varied from 6 to 7 for 35 per cent of the
subjects and 9 to 8 for 30 per cent, and 35 per cent of the subjects
attributed score 10 to their smiles.
Also, 60 per cent of the subjects answered that they did not have
complaints about their smiles. The most frequent complaints were
teeth colour (five subjects), dental or rehabilitation problems (three
subjects), alignment (two subjects), tooth wear (two subjects), miss-
ing teeth (one subject), and interdental spaces (one subject).
The major occlusal changes noticed by the subjects from adoles-
cence to the sixties were crowding (five subjects), dental wear (four
 4 European Journal of Orthodontics, 2018

Table 1.  Objective grading system time points comparisons. SD, standard deviation

T1 T2 Difference

Mean (SD) Mean (SD) Mean (SD) 95% confidence interval P

Alignment 8.90 (2.98) 10.40 (3.47) −1.50 (3.83) −3.293, 0.293 0.096
Marginal ridges 3.89 (0.87) 2.21 (1.58) 1.68 (1.73) 0.849, 2.520 <0.001*
Buccolingual inclination 8.44 (3.38) 5.00 (2.95) 3.44 (3.74) 1.582, 5.307 0.001*
Overjet 4.15 (3.64) 6.31 (6.36) −2.15 (6.29) −5.190, 0.875 0.152
Occlusal contacts 3.33 (3.08) 4.16 (3.12) −0.83 (4.55) −3.098, 1.431 0.448
Occlusal relationship 2.72 (2.73) 6.33 (4.58) −3.61 (3.97) −5.587, −1.636 0.001*
Interproximal contacts 4.15 (4.86) 1.85 (2.79) 2.30 (5.38) −0.219, 4.819 0.071
Total 33.20 (8.03) 34.30 (12.40) −1.10 (13.42) −7.383, 5.183 0.718

*Statistically significant at P less than 0.05.

Table 2.  Objective grading system time points comparisons without tooth losses (n = 9). SD, standard deviation

T1 T2 Difference

Mean (SD) Mean (SD) Mean (SD) 95% confidence interval P

Alignment 8.67 (1.73) 11.89 (2.47) −3.22 (2.90) −5.456, −0.989 0.010*
Marginal ridges 4.33 (0.70) 2.56 (1.13) 1.77 (1.20) 0.854, 2.702 0.002*
Buccolingual inclination 8.67 (3.08) 5.78 (3.27) 2.88 (2.84) 0.700, 5.078 0.016*
Overjet 3.00 (2.69) 5.11 (5.11) −2.11 (5.15) −6.076, 1.854 0.254
Occlusal contacts 2.89 (2.08) 5.44 (3.04) −2.55 (3.60) −5.330, 0.219 0.066
Occlusal relationship 2.56 (2.78) 5.11 (4.16) −2.55 (3.74) −5.434, 0.323 0.075
Interproximal contacts 6.11 (5.79) 1.22 (2.22) 4.88 (5.46) 0.688, 9.089 0.028*
Total 33.89 (7.94) 37.11 (7.54) −3.22 (8.21) 3.090, −1.177 0.273

*Statistically significant at P less than 0.05.

subjects), tooth discoloration (four subjects), chewing impairment
(three subjects), tooth loss (three subjects), interdental spaces (two
subjects), and third molar eruption (one subject). Eight out of 20 sub-
jects reported they had crowded teeth with a median of discomfort
of 0.5 in a scale of 0 (very unhappy) to 10 (no discomfort). Desire
to undergo orthodontic treatment was not reported in this sample.
Discussion
This is the only study that followed the normal occlusion until the
seventh decade of life. Two qualitative methods were used in this
study. The OGS assigns scores for eight qualitative parameters of the
occlusion. The greater the score, the worse is the quality of the occlu-
sion (9). The critical score used by the ABO is 30 for treated cases
(9). The ICC showed good to excellent intraexaminer reproducibil-
ity for the OGS analysis. The examiner was initially trained and the
measurements were performed following the ABO instructions (9).
A metal gauge, commercialized by the ABO, was used for all meas-
urements. The angulation criteria were excluded of the OGS analysis
due to the absence of panoramic radiographs, which is a limitation
of this study. Previous studies also showed excellent repeatability of
the OGS analysis (14, 15). The SKNO were additionally used in this
study to provide better appraisal of individual tooth variation (10).
The kappa coefficient showed substantial to almost perfect repeat-
ability for the SKNO analysis. Kattner and Schneider (16) also used
the SKNO to evaluate the quality of orthodontic treatment with dif-
ferent bracket prescriptions and found no significant differences for
the interexaminer repeatability. The sample of this study was initially
selected before publication of the SKNO (10). Therefore, in some
cases, some normal deviations were expected at T1.
There were significant changes for three out of seven of the OGS
parameters. The marginal ridge scores significantly improved with
aging. This improvement could be justified by the occlusal tooth
wear, which is a physiologic consequence of aging (17–20). The buc-
colingual inclination of posterior teeth showed a slight improvement
from T1 to T2 both in the complete sample and in the subgroup
without tooth loss. These changes were small and not considered
clinically relevant.
As an unexpected result, aging maturation slightly deteriorated
the sagittal–occlusal relationship in some subjects according to the
OGS. Two individuals out of 20 (two males) showed development
of a slight Class III relationship and decreases in overbite and overjet
at T2, although a Class  I  facial pattern was still present (Figures  4
and 5). No previous study evaluated qualitative changes of interarch
sagittal relationship with aging. Possible explanations for deterior-
ation of the antero-posterior occlusion are late Class III malocclusion
pattern manifestation, greater mandibular anterior displacement with
growth, or even greater physiologic mesial migration in the mandibu-
lar arch (3). Also, tooth loss might have had an effect on the sagittal–
occlusal relationship considering that individuals without tooth loss
showed no significant deterioration. Another observation was that
individuals with Class  III relationship and an edge-to-edge incisor
relationship at T2 showed pronounced occlusal tooth wear (Figures 4
and 5). The assumption of a possible association between tooth wear
and the changes in occlusal relationship should be further studied.
Tooth loss may attenuate the occurrence of dental misalignment
at 60 years of age. A statistically significant deterioration in the align-
ment was found only for the subgroup without tooth loss. Late anterior
crowding of the mandibular arch is one of the most reported changes
of the maturational process and they are unpredictable (2–4, 7, 21–25).

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 F. Miranda et al. 5

Table 3.  Time points comparisons for the six keys to normal occlusion. Mx., maxillary; Md., mandibular

T1 presence (%) T2 presence (%) P

Key 1 Interarch relationship 52.63 31.57 0.220

Key 2 Mx.1 95.00 75.00 0.220
Mx.2 85.00 90.00 1.000
Mx.3 55.00 80.00 0.130
Mx.4 65.00 85.00 0.288
Mx.5 60.00 80.00 0.288
Mx.6 94.44 83.33 0.617
Mx.7 12.50 50.00 0.041*
Md.1 40.00 35.00 1.000
Md.2 45.00 20.00 0.130
Md.3 55.00 70.00 0.449
Md.4 63.15 73.68 0.751
Md.5 60.00 80.00 0.288
Md.6 78.94 84.21 1.000
Md.7 76.47 94.11 0.248
Key 3 Mx.1 95.00 95.00 0.479
Mx.2 100.00 95.00 1.000
Mx.3 90.00 90.00 —
Mx.4 100.00 80.00 0.133
Mx.5 100.00 80.00 0.133
Mx.6 66.66 61.11 1.000
Mx.7 87.50 31.25 0.007*
Md.1 100.00 75.00 0.073
Md.2 100.00 100.00 —
Md.3 100.00 100.00 —
Md.4 100.00 89.47 0.479
Md.5 95.00 95.00 0.479
Md.6 100.00 73.68 0.073
Md.7 94.11 58.82 0.041
Key 4 Mx.1 95.00 90.00 1.000
Mx.2 50.00 70.00 0.220
Mx.3 75.00 70.00 1.000
Mx.4 30.00 40.00 0.683
Mx.5 60.00 40.00 0.288
Mx.6 83.33 72.22 0.479
Mx.7 93.75 62.50 0.073
Md.1 60.00 20.00 0.026
Md.2 60.00 35.00 0.073
Md.3 70.00 60.00 0.723
Md.4 52.63 63.15 0.723
Md.5 50.00 55.00 1.000
Md.6 100.00 94.44 1.000
Md.7 88.23 82.35 1.000
Key 5 Maxillary right posterior 95.00 100.00 1.000
Maxillary anterior 55.00 75.00 0.288
Maxillary left posterior 90.00 95.00 1.000
Mandibular right posterior 94.11 100.00 1.000
Mandibular anterior 70.00 80.00 0.617
Mandibular right posterior 100.00 100.00 —
Key 6 Curve of Spee—right 68.75 100.00 0.073
Curve of Spee—left 63.15 84.21 0.288

*Statistically significant after Holm–Bonferroni correction for multiple comparisons (McNemar test).

Mandibular tooth irregularity appears to increase throughout life
regardless of the orthodontic treatment (2, 24). Sinclair and Little (2)
found that incisor irregularity increased twofold faster in orthodontic-
ally treated subjects when compared to an untreated normal occlusion
sample. Little (24) reported that the degree of dental crowding devel-
oped after retention is variable and unpredictable. As a clinical consid-
eration, a mandibular canine-to-canine fixed retainer might be indicated
even in nontreated individuals with normal occlusion to prevent late
mandibular incisor crowding. In addition, minor diastemas decreased
in subjects without tooth losses probably as a result of the physiologic
mesial migration of maxillary and mandibular posterior teeth.
The SKNO analysis showed significant changes from 13 to
60 years of age for the maxillary second molar angulation and max-
illary second molars inclination. The maxillary second molar angu-
lation significantly improved with aging. Eight out of 20 individuals
with an initial distoangulation of the maxillary second molar showed
a normal positive angulation at T2. Andrews’ (11) sample of nor-
mal occlusion also showed individuals with maxillary second molar

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 6 European Journal of Orthodontics, 2018

Figure 3.  Tooth loss observed in the sample. Teeth were numbered according to the Federation Dentaire Internationale (FDI) World Dental Federation notation (13).

Figure 4.  Male subject at 13.2 (A) and 61.7 years of age (B). Notice the severe pattern of occlusal tooth wear and the edge-to-edge incisor relationship at T2. Right
and left first molars were lost in this subject (B).

distoangulation. These results suggest that maxillary second molar dis-
toangulation is temporary and adjust with time, at least in individuals
with normal occlusion. Before eruption, the second molar crown is
usually distally angulated, and after eruption, the apex spontaneously
moves distally (26, 27). This tendency of second molar uprighting
seems to continue after 13 years of age in normal occlusion individu-
als. Self-correction of maxillary second molar distoangulation with
time suggests that correction of this feature in orthodontic patients
during the early permanent dentition might constitute an overtreat-
ment and should be avoided to decrease treatment time. Tooth losses
are a limitation in this study, and therefore these results should be
analysed with caution. Tooth losses might have had an influence on
the improvement of maxillary second molar angulation.
Crown buccolingual inclination of maxillary second molars dete-
riorated with the maturation process. Second molar crowns were
buccally tipped and displaced at T2 (Figure 6). No previous report
on this regard was found. A speculation is that the increase of second
molar buccal torque may be related to third molar development and
eruption. Another possible explanation is a decrease in buccinator
muscle tonicity, with age, that should be further investigated. The
number of second molar absences in T2 could also have underesti-
mating changes for this variable.
The limitation of this study was the high prevalence of tooth
loss in the sample (70 per cent). Permanent tooth loss was preva-
lent in the posterior region and in the mandibular arch. Previous
studies also found similar tooth loss rates (1.4 missing teeth, on

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 F. Miranda et al.
Figure 5.  Male subject at 13.9 (A) and 61.6 years of age (B). Notice the slight molar Class III relationship and the edge-to-edge incisor relationship at T2 (B).
Figure 6.  Second molar buccal displacement from T1 to T2. (A) Male subject
at 14 and 63.4 years of age. (B) Male subject at 13.9 and 61.6 years of age.
average) in a normal occlusion sample of 18 individuals at 65 years
of age (28, 29). The generation of our sample shows high rates
of dental caries and tooth extraction because they did not experi-
ence water fluoridation, fluoride dentifrices, changes in perception
of oral health/oral hygiene, and regular use of dental services and
technologies (30–32).
Finally, a secondary analysis was performed to evaluate the indi-
vidual’s perceptions of their own occlusion and dental aesthetics.
Dental crowding was the most prevalent change noticed, causing
dissatisfaction in 35 per cent of the sample. Most individuals were
highly satisfied with their smiles, in accordance with previous stud-
ies in normal occlusion subjects (28, 29). Although subjects reported
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7
changes as tooth loss, dental prosthesis, and other dental changes
as tooth wear and enamel staining, self-perception of aesthetics
and function was not substantially affected. None of the patients
had the desire to undergo orthodontic treatment, and none of them
had orthodontic treatment performed from T1 to T2. According to
Stenvik et  al. (29), individuals with normal occlusion evaluated at
65 years of age reported favourable experiences related to their teeth
and occlusion when compared to individuals with malocclusion.
Corroborating our results, individuals with normal occlusion at
65 years of age were found highly satisfied with their occlusion and
without any desire to undergo orthodontic treatment after a long
follow-up period (28). It is important to highlight that this question-
naire was not previously validated, and the self-perception results
should be regarded with caution.
Although some changes were found in the quality of the occlu-
sion, the general quality remained stable throughout the years with a
high level of individual satisfaction at 60 years of age. Future studies
should analyse the skeletal and facial changes with aging in indi-
viduals with normal occlusion. The association between tooth wear
and incisor crowding in normal occlusion individuals should also
be evaluated.
Conclusions
1. Aging slightly deteriorates the quality of normal occlusion.
2. Maxillary second molar tipped buccally from 13 to 60  years of
age.
3. Levelling of marginal ridges improved with tooth wear.
4. Maxillary second molar showed a change of mesiodistal angula-
tion with mesial movement of the crown during the observation
time.
5. Subjects without tooth loss showed a more significant tooth align-
ment worsening than subjects with tooth loss.
 8 European Journal of Orthodontics, 2018
6. The mean number of tooth loss at 60 years of age was 2.1 teeth per
individual. Only 30 per cent of the subjects had no tooth loss.
7. Most of the subjects with normal occlusion demonstrate satisfac-
tion with their smile aesthetics and occlusal comfort at the sixth
decade of life
Funding
This work was supported by CAPES—‘Coordination for the improvement of
higher education personnel’. Authors thank CAPES for the provided funding.
Conflict of interest
None declared.
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