Original article

PATTERN OF DENTAL MALOCCLUSION IN ORTHODONTIC PATIENTS IN

RWANDA: A RETROSPECTIVE HOSPITAL BASED STUDY
Goyal Sandeep 1,*
, Goyal Sonia 2

1
Orthodontist, Dental Department, King Faisal Hospital, Kigali, Rwanda
2
Stomatologist, Polyclinique La Medicale, Kigali, Rwanda

ABSTRACT
Background: Dental malocclusion is present in all societies but its prevalence varies. Identifying occlusal problems, their incidence and the need
for treatment can help to determine the appropriate awareness plans, preventive and interceptive treatment and manpower needed in orthodontics.
There is no study of such kind to evaluate the pattern of malocclusion in Rwandese population.
Aim: The aim of the study was to analyze and to provide quantitative information on the pattern of dental malocclusion among orthodontic population
in Rwanda.
Methods: Various parameters retrieved from patients’ records of 243 selected patients with dental malocclusion who visited Dental Department of
King Faisal Hospital, Rwanda, during the period of January 2009 to July 2012 were analyzed in this retrospective study. Chi-square test was used
to find the gender difference at p < 0.05.
Results: Angle’s Class I malocclusion was found to be the most common malocclusion with 60.9 % followed by 28.8 % Angle’s class II and 10.3 %
Angle’s class III. Increased crowding (71.2 %) was the most common problem, followed by increased overjet, deep bite and anterior open bite in
that order. No significant gender differences were found except in deep bite.
Conclusion: The results give a pattern of malocclusion in orthodontic patients and may provide a base line data for planning awareness programs,
preventive and interceptive orthodontic services & the future studies. There is a strong need of multicentric, epidemiological survey to find out the
prevalence & causes of malocclusion in Rwandese population.

Keywords: Angle’s classification - pattern of malocclusion - open bite - crowding - orthodontics

RESUME

Fond : Malocclusion dentaire est présent dans toutes les sociétés mais sa prédominance varie. En s’identifiant occlusal les problèmes, leur incidence
et le besoin pour le traitement peuvent aider à déterminer les plans de conscience appropriés, le traitement préventif et intéroceptive et la main-
d’œuvre nécessaire dans l’orthodontie. Il n’y a aucune étude d’une telle sorte pour évaluer malocclusion dans la population Rwandaise.
But : le but de l’étude était d’analyser et fournir des informations quantitatives sur le dessin de malocclusion dentaire parmi la population orthodontique
au Rwanda.
Méthodes : les paramètres malocclusion dentaires différents de 243 patients choisis qui ont visité le Département Dentaire d’Hôpital de Roi Faysal,
Kigali, le Rwanda pendant la période de janvier de 2009 jusqu’au juillet de 2012 ont été analysés dans cette étude rétrospective. L’épreuve Chi-carrée
a été utilisée pour trouver la différence de genre à p <0.05.
Résultats : la Classe d’Angle de malocclusion qui a été trouvée pour être la plus commune avait 60.9 suivi par la classe d’angle II de 28.8, et 10.3 la
classe d’angle III. L’entassant augmenté (71.2) était le problème le plus commun, suivi par augmenté suren jais, mordre profondément et le morceau
ouvert antérieur dans cet ordre. Aucune différence de genre significative n’a été trouvée sauf dans le morceau profond.
Conclusion : les résultats donnent un dessin de malocclusion dans les patients orthodontiques et peuvent fournir des données de ligne des bases
à planifier des programmes de conscience, les services orthodontiques préventifs et interceptive * les études futures. Il y a un fort besoin d’enquête
multicentrale, épidémiologique de découvrir la prédominance * les causes de malocclusion dans la population Rwandaise.

Mots-clés: la classification d’Angle - le dessin de malocclusion - ouvrez le morceau - le fait d’entasser - Orthodontie

INTRODUCTION

Occlusion is defined as the relationship of the maxillary otherwise helps to accommodation of teeth in dental
and mandibular teeth as they are brought into functional arches in aligned manner.
contact; while malocclusion is the state of any deviation The World Health Organization (1987) [3], had included
from the normal or ideal occlusion, as defined in the malocclusion under the heading of Handicapping Dento-
Glossary of Orthodontic Terms [1]. Malocclusion is an Facial Anomaly, defined as an anomaly which causes
appreciable deviation from the ideal occlusion that may disfigurement or which impedes function, and requiring
be considered aesthetically unsatisfactory (Houston, et treatment “if the disfigurement or functional defect
al., 1992) [2] thus implying a condition of imbalance was likely to be an obstacle to the patient’s physical or
in the relative sizes and position of teeth, facial bones emotional well-being”.
and soft tissues (lips, cheek, and tongue). Malocclusion Malocclusions feature the third highest prevalence among
is a common condition in the modern civilization due to oral pathologies, second only to tooth decay and periodontal
adoption of soft food and lack of stimulus of the proper disease, and therefore rank third among worldwide
jaw growth, and proximal attrition of teeth, which Public Health dental disease priorities3. According to the
World Health Organization [3], the main oral diseases
*Correspondence to: Dr Sandeep Goyal, BDS, MDS, should be subjected to periodic epidemiological surveys
Orthodontist, Dental Department for planning and providing prevention and treatment
King Faisal Hospital, Kigali, Rwanda
Ph: 0783012622
Email: [email protected]

Rwanda Medical Journal / Revue Médicale Rwandaise 13 RMJ Vol.69 (4); December 2012
G. Sandeep et Al. Pattern of dental malocclusion in Rwanda

services [4]. Knowledge about the distribution of June 2012 with chief complaints of irregularity of teeth.
different malocclusions helps orthodontic practitioners to The patients were between 8 years to 35 years of age.
understand the existent problem in a geographic location Clinical examination of 312 patients was performed by
and help them in the planning awareness and preventive an Orthodontist & findings were recorded in the medical
programs. record files of each patient, but only 243 patients were
included in this study based on the selection criteria. Thus,
REVIEW OF LITERATURE the study included 124 males and 119 females between
the ages of 10 – 30 years.
Dental malocclusion is present in all societies but its
prevalence varies in different parts of the world among The following selection criteria were used:
various populations. Ethnic, genetic and environmental 1. The age range of patients between 10 – 30 years
factors lead to development of malocclusion. Many 2. Patients had no history of previous orthodontic
epidemiological studies have been conducted to treatment.
determine the prevalence of mal-occlusion in different 3. They had permanent teeth only.
racial and ethnic groups with variable results [5]. Savara 4. There is no systemic disease, craniofacial deformities
(1955), in a study on children aged 14-17, reported the or syndrome.
prevalence of normal occlusion, 21.1%; Class I, 50.1%; 5. All the patients were of Rwandese origin; the patients
Class II, 19.4% and Class III, 9.4% [5]. Jackson and of Burundi, Uganda and DR Congo were not included.
Brehm (1961), in their study on 6328 children aged
6-18, found the prevalence of normal occlusion, 16.6%; The following parameters were recorded. The antero-
Class I, 60.1%; Class II, 22.8% and Class III, 0.5% [5]. posterior relationships of the maxillary and mandibular first
Mills (1968), in his study on 1337 teenagers aged 13- molars in maximum intercuspation by Angle’s classification
14, reported the prevalence of normal occlusion, 17.5%; [9]; crowding; spacing; increased overjet (more than 3
Class I, 72.2%; Class II, 6.6% and Class III, 3.7% [5]. A mm), increased overbite (more than 3 mm), open bite;
study on 3289 black American adolescents aged 12-14, deck biss pattern of incisors; and mandibular prognathism
yielded the prevalence of normal occlusion, 16.6%; Class as evaluated clinically. The data were obtained through
I, 67.8%; Class II, 12.1% and Class III, 5% [5] A study direct clinical examination by an orthodontist. Various
on 919 teenagers in Kenya, aged 13-15, reported that the classes of malocclusion according to Angle’s classification
prevalence of malocclusion was as high as 72%. In this & other parameters studied are as described below [10].
study crowding, increased overjet, and open bite were
found in 19%, 10%, and 8% of the cases, respectively • Angle’s Class I relation: Mesiobuccal cusp of
[6, 7]. the maxillary first permanent molar articulates in the
mesiobuccal groove of the mandibular first permanent
A study done in Benin City, Nigeria on 229 males and molar.
212 females of mean age 13.52 years ± 1.83 showed • Angle’s Class II relation: The mesiobuccal cusp
that 15.9% of the subjects had normal occlusion, 80.7% of maxillary first permanent molar articulates mesial to
had Angle’s class I and 1.1% had Angle’s class II div mesiobuccal groove of mandibular first molars. Angle’s
1, 0.5% had Angle’s class II div 2 and 1.8% Angle’s Class II Division 1: A class II relation in which maxillary
class III malocclusion. Increased overjet and overbite incisors are inclined labially, and increased overjet is
was observed in 24.7% and 9.8% respectively. Anterior present. Angle’s Class II Division 2: A class II relation in
open bite was present in 4.1%. Crowding in the upper which maxillary central incisors are inclined lingually, and
(11.1%) and lower anterior segment (12%) were similar maxillary lateral incisors have tipped labially and mesially,
while spacing was more prevalent in the upper (29.9%) covering the distal of central incisors. The overjet is
than the lower anterior segment (10.7%) with midline reduced, and there is deep bite of partial / complete /
diastema present in 19.5%. The occlusal traits were not traumatic / more than 100% nature.
influenced by gender difference (P>0.05). The survey • Angle’s Class III relation: The mesiobuccal cusp
revealed predominance of Class I malocclusion among of maxillary first permanent molar occludes distal to
Nigerian children in Benin City [8]. mesiobuccal groove of mandibular first molars. However,
On extensive search of literature, no such study could subdivisions of Angle’s class II & III were not considered
be found depicting the pattern of malocclusion in non- during this study.
orthodontic Rwandese children; and the Rwandese • Class IV relation: When there is Angle’s Class II
patients seeking orthodontic treatment. This is the first relation on one side & Class III relation on other side of
study of its kind which aims at understanding the pattern the dental arches in occlusion.
of malocclusion & dental irregularities among patients • Deck biss: It is the upper incisors arrangement in div 2
who visited for orthodontic treatment at the Dental and pattern while molar relation is Angle’s class I.
Orthodontic Department of King Faisal Hospital, Kigali, • Overjet was defined as the horizontal distance between
Rwanda, and to find the gender differences if any; and to the incisal edge of the most prominent maxillary central
provide recommendations for future studies. incisors to the labial surface of corresponding mandibular
central incisors. It was measured with a graduated scale
METHODS and evaluated to the nearest 0.5mm. An overjet greater
than 3 mm was considered to be increased.
This retrospective study included those patients who • Overbite is the vertical relationship of the upper and
visited the Dental Department of King Faisal Hospital, lower incisors. It was recorded as increased when the
Kigali, Rwanda during the period of January 2009 to maxillary central incisors covered the mandibular central

Rwanda Medical Journal / Revue Médicale Rwandaise 14 RMJ Vol.69 (4); December 2012
G. Sandeep et Al. Pattern of dental malocclusion in Rwanda

incisors by more than 3 mm. Table 2: Showing data divided according to sex and their
• Anterior open bite was recorded when incisal edges frequency distribution; Charts 3, & 4
of the maxillary incisors did not overlap the incisal edges
of the mandibular incisors. S. No. Parameters Males, N = 124 Females, N = 119
• Crowding was defined as overlapping of erupted
N % N %
teeth due to insufficient space or lack of space for teeth
to erupt in the dental arch. 1. Angle’s class I 70 56.5 78 65.5

• Spacing was recorded to be present when there was

no approximal contact between 2 teeth in a dental arch. 2. Angle’s class II, total 42 33.9 28 23.5

However, no quantitative or qualitative measurement

for crowding & spacing was done in any arches. It was 3. Angle’s class II, div 1 41 33 28 23.5
just recorded as either present or absent in either of the
dental arch. No segregation was done for upper or lower 4. Angle’s class II, div 2 1 0.8 0 0
arch.
5. Angle’s class III 12 9.7 13 11
RESULTS
6. Class IV 0 0 1 0.85
The results were presented in a descriptive fashion
using absolute numbers & the percentage of different 7. Deck biss 1 0.8 0 0
types of conditions for both sexes separately. Pooled
data was also evaluated for finding the distribution 8. Crowding 82 66.1 91 76.5
of various conditions. Statistical significance for any
sexual dimorphism between different parameters was 9. Spacing 11 8.9 13 10.9
evaluated with the chi-square test and p<0.05 was
regarded as significant. Results have been presented in 10. Open bite 28 22.6 31 26
Tables 1, and 2; and Charts 1 – 4. There was significant
difference between occurrence of the 3 classes of Angle’s 11. Deep bite 49 39.5 28 23.5*
malocclusions (Table 1, chi square test, at P <0.01).
There were no significant gender differences among all 12. Increased overjet 60 48.4 48 40.3
the parameters studies except deep bite (Table 2, chi
square test, at P <0.05) which was found to be more in
13. Mandibular prognathism 5 4 5 4.2
males as compared to females.
 
Table 1: Showing pooled data and frequency distribution; * significant at p < 0.05, chi square test
Charts 1 & 2

S. No. Parameters Total N = males + Frequency %

females = 243

1. Angle’s class I 148 60.9** Angle’s  class  I  

Angle’s  class  II  
Angle’s  class  III  

2. Angle’s class II 70 28.8**

 
3. Angle’s class III 25 10.3**
Figure 1: showing frequency distribution of Angle’s class I, II & III
4. Crowding 173 71.2 malocclusions.

5. Spacing 24 9.9

Crowding  
6. Open bite 59 24.3
Spacing  
Open  bite  
Deep  bite  
7. Deep bite 77 31.7
Increased  overjet  
Mandibular  prognathism  

8. Increased overjet 108 44.4

 

9. Mandibular prognathism 10 4.1 Figure 2: Showing frequency distribution of crowding, spacing, open
bite, deep bite, overjet and mandibular prognathism conditions.
 

Rwanda Medical Journal / Revue Médicale Rwandaise 15 RMJ Vol.69 (4); December 2012
G. Sandeep et Al. Pattern of dental malocclusion in Rwanda

In our study, Angle’s class II division 2 malocclusion was

70   very low, (1 out of 243 subjects). A study by DaCosta [14]
60  
found only 1.7% children in Northern Nigerian had Angle’s
50  
40  
class II division 2 malocclusion, while Ajayi8 found it at
30  
0.5 % level in his study. However a study in the British
20   males  %   population shows higher prevalence rates ranging from 8
10   females  %   - 27% [15-17].
0   The frequency of Angle’s class III malocclusion of 10.3 %
in our sample, but it is different from the low prevalence
reported in Nigerian children [18-19] and of 1% in
Tanzanian children [20]. However, Garner & Butt 1985 [21]
in their study on Kenyan children found higher prevalence
 
of 16.8% of Class III.
Figure 3: Showing gender distribution of different classes of
Deck biss and Class IV relation each were also found in
1 out of 243 cases only, which is quite negligible. These
malocclusion & conditions
features have not been evaluated in any other studies
done on African children.
80  
70  
60   Increased crowding (71.2 %) in the sample studies was
50   very high and thus the causes of crowding should be
40  
30   looked into in the future studies, so that proper preventive
20  
males  %   actions could be taken by creating awareness campaigns.
10  
0   females  %   Although frequency of crowding was more in females as
compared to males, but the difference was not statistically
significant. Drummonds [22] found only 40 % children
having crowding in the study done in South Africa. The high
percentage of crowding may be partly explained by the
frequent occurrence of caries and molar extractions, which
 
favors the migration of first permanent molars, inclinations
Figure 4: Showing gender distribution of different conditions of and rotations [11]. Genetics and racial differences
malocclusion controlling the growth of jaws; evolutionary trends in jaw
growth; premature extractions of baby teeth without any
DISCUSSION space maintenance; unrestored caries and space loss;
Ibyinyo (a type of oral mutilation i.e. a traditional practice
in some parts of Rwanda and Africa where the tooth
The reported prevalence of malocclusion in different buds of certain baby teeth are gouged out in early age to
parts of the world varies from 39% to 93% [11]. The prevent GIT infections in a child); iatrogenic malocclusion
evaluation of orthodontic patients may give valuable created by extraction of certain permanent teeth by non
information for planning orthodontic treatment. The – orthodontists & other dentists etc can be some of the
prevalence of malocclusion varies from one geographical factors which may have contributed to increased crowding,
area to another and differs from one country to another which should be looked into in future studies. In the
country and even from one city to another city. Angle’s posterior segments, these events are associated with the
classification [15] is useful for easy documentation and early loss of deciduous molars and, consequently, loss of
provides a common channel of communication among space. On the other hand, spacing was found to be present
dental professionals. It is an easy and rather accurate in only 9.9 % cases, thus showing the general trend
way to categorize malocclusions, and is globally used in worldwide that crowding is more prevalent than spacing
dental profession. due to evolutionary trends and dietary habits. However,
the presence of spacing needs to be studied in depth to
In the present study, Angle’s Class I malocclusion was find out the related causes.
found to be the most common malocclusion with 60.9 % High percentage of open bite 24.3 % is consistent with
followed by 28.8 % Angle’s class II and 10.3 % Angle’s some studies in African children (Kenya 11.4%; Nigeria
class III among the orthodontic patients examined. This 7 – 10.2 %; Tanzania 8 %) [23-28] which can be due
finding is consistent with other studies. Proffit et al [12] to heredity and racial differences as compared to White
found in untreated White Americans of 8 - 50 years age, population. In a dissertation study done by Drummonds
the Angle’s Class I malocclusions was most prevalent, in 200322 in South Africa, he found the anterior open
i.e., 52.2%, while 42.4% were Angle’s Class II and less bite at 7.7 %, he also found that the open bite was more
than 5% were Angle’s Class III malocclusions. Another prevalent among Blacks as compared to Whites & Asians;
study on the pattern of malocclusion in Africa (Nigeria) and females were more affected than males. Otuyemi et
[13] showed Angle’s Class I at 76.5%, Class II 15.5% al [29] in a study in Nigeria found 10.2 % prevalence of
and Class III 8.0%. open bite.
IN the present study, Angle’s class II division 1 Several factors have a role in the pattern of different kinds
malocclusion was at 28 %, which is very high as of malocclusion among populations. These contributing
compared to studies reported from Nigeria by Ajayi [8], factors could be considered as the time of the study. Eg
who reported only 1.5 %.
Rwanda Medical Journal / Revue Médicale Rwandaise 16 RMJ Vol.69 (4); December 2012
G. Sandeep et Al. Pattern of dental malocclusion in Rwanda

the causes of open bite may be due to chronic nasal be representative of the whole of the population. Also,
allergy and mouth breathing habits in Rwandese children in view of the biased nature of the sample, the data of
which should be explored in further studies with the this orthodontic population cannot be extrapolated to the
collaboration of ENT surgeon. whole of the Rwanda population. There is a strong need of
analyzing the prevalence of malocclusion in Rwanda.
An increased overjet 44.4 % was found in the present
study. In a dissertation study done by Drummonds in In view of findings of the current study, following
2003 [28] in South Africa, he found the approx 32 % recommendations can be enumerated:
subjects had increased overjet, in which Blacks had less
prevalence as compared to Whites; and boys were more • There is a strong need to conduct epidemiological studies
than girls. In the present study, we found high percentage on the population of Rwanda to find out the prevalence of
of overjet, with no sexual dimorphism. It may be due to malocclusion.
racial and genetic differences, and may also be associated • Additional criteria should be used in future studies
with mouth breathing habit which leads to downward & involving large number of subjects with random sampling,
backward mandibular rotation, increased anterior facial countrywide, multi-centric studies should be conducted.
height, and convexity of profile, which also needs to be • The causative factors of the irregularity of teeth and
explored in future studies. Studies done in Nigeria show other malpositions should also be evaluated simultaneously
that there, the normal overjet is more frequent while so that preventive and interceptive measure could be
only 25 % showed increased overjet. Isiekwe [30-31] planned.
also reported that 58% subjects had normal overjet, and • The ENT surgeon needs to be associated in the study to
he attributed it to the possibility of bimaxillary protrusion evaluate the patients for chronic nasal allergy and mouth
which is prevalent in Black race. breathing habits to associate their relation with the open
Deep bite was found to be in approx 32 % cases in our bite etc.
study. It is very high as compared to studies done in • Proper awareness programs should be started to educate
Nigerian where normal overbite relation was found to be the masses and the school children to avoid the causative
more [32-35] Only 9.8 % patients were having deep bite factors leading to malocclusion e.g. prevention of caries,
in the study done by Ajayi in Nigeria [8]. The difference trauma etc.
may be due to differences in facial growth pattern and • The dental health manpower should be educated and
racial differences. There was significant gender difference trained so that they can manage the space left after
in deep bite which was found to be more in males as premature extraction of baby teeth, or they should be
compared to females in our sample. sensitized to refer such patients to specialist for space
management.
CONCLUSION • The resources for minor and major orthodontic treatments;
space maintainers and other preventive therapies should
In this retrospective, preliminary, hospital based study, be made available in the hospitals and clinical settings.
the frequency of Angle’s Class I, Class II and Class III • Since the early treatment can be done for some of these
malocclusion was found to be 60.9%, 28.8% and 10.3% conditions so that their severity does not increase with age,
respectively. Out of all the problems studied, crowding it shows the importance of having children assessed during
was found to be the most common feature, followed by the mixed dentition. Early treatment is also recommended
increased overjet, deep bite and anterior open bite in in severe cases of excessive overjet to prevent dental
that order. Identifying occlusal problems, their incidence trauma and improve lip function and breathing, esthetics
and the need for treatment can help to determine the and psychological well being of the children.
appropriate treatment plan and manpower needed in • The insurance providers should be educated & sensitized
orthodontics. Such epidemiological surveys are extremely that they should not insist that orthodontic intervention
important as they can help in finding the factors leading can only be done in permanent teeth. There are certain
to malocclusion, and thus help in planning the preventive conditions which need to be treated during mixed dentition
and interceptive actions and awareness programs for period also to prevent the future development of skeletal,
the population. The results may also provide a base functional and esthetic problems.
line data for planning orthodontic services but cannot

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Rwanda Medical Journal / Revue Médicale Rwandaise 18 RMJ Vol.69 (4); December 2012