Eur Arch Paediatr Dent
DOI 10.1007/s40368-013-0069-9
ORIGINAL SCIENTIFIC ARTICLE
Malocclusion in preschool children: prevalence
and determinant factors
P. Corrêa-Faria • M. L. Ramos-Jorge • P. A. Martins-Júnior
R. G. Vieira-Andrade • L. S. Marques
Received: 28 March 2013 / Accepted: 27 June 2013
Ó European Academy of Paediatric Dentistry 2013
Abstract
Purpose To evaluate the prevalence of malocclusion and
associated factors in the primary dentition of preschoolers
in the city of Diamantina, Brazil.
Methods A cross-sectional study was carried out with 381
children aged 3–5 years treated at the 10 basic health care
units in the city during immunisation campaigns. The
dependent variables (presence of malocclusion, open bite,
crossbite and crowding) were evaluated through a clinical
oral exam. The independent variables (gender, age, health
problems, breastfeeding, bottle feeding, harmful oral hab-
its, mother’s schooling, household income and number of
children in the home) were collected through interviews.
Statistical analysis involved descriptive analysis, Chi
square test and Poisson regression.
Results The prevalence of malocclusion was 32.5 %.
Open bite was the most frequent type of malocclusion.
Children with a history of bottle feeding (PR 1.74; 95 % CI
1.24–2.44) and those with harmful oral habits (PR 1.49;
95 % CI 1.23–1.99) had greater prevalence rates of mal-
occlusion. Greater prevalence rates of open bite were also
found in children with a history of bottle feeding (PR 5.00;
95 % CI 1.99–12.5) and those with harmful oral habits (PR
2.90; 95 % CI 1.59–5.29), whereas greater prevalence rates
of crossbite were found in boys (PR 1.79; 95 % CI
1.10–2.91) and were associated with mother’s schooling
(PR 1.91; 95 % CI 1.20–3.06).
P. Corrêa-Faria (&)
M. L. Ramos-Jorge

P. A. Martins-Júnior
R. G. Vieira-Andrade
L. S. Marques
Federal University of Vales do Jequitinhonha e Mucuri,
Rua da Glória, 187, Centro, Diamantina, Minas Gerais, Brazil
e-mail: patriciafaria.faria09@gmail.com
•
Conclusion A history of bottle feeding and the presence
of harmful oral habits were identified as determinants for
the occurrence of malocclusion in preschoolers.
Keywords Malocclusion
Primary teeth
Epidemiology
Introduction
Malocclusion is a dental disorder related to changes in the
growth and development of the craniofacial system that
affects both function and aesthetics, thereby exerting an
influence on quality of life and social interactions
(Cunningham and Hunt 2001; Marques et al. 2005; Peres
et al. 2007; Liu et al. 2009). The high prevalence rates
make malocclusion a worldwide public health problem
(WHO 1997). According to the literature, the prevalence
of malocclusion ranges from 26.0 % (Dhar et al. 2007) to
as high as 87.0 % (Leite-Cavalcanti et al. 2007). Anterior
open bite and crossbite (Hebling et al. 2008; Carvalho
et al. 2011) are the most common types of malocclusion
found in children.
The aetiology of malocclusion is related to the interac-
tion of hereditary and environmental variables, including
stimuli during the formation and development of orofacial
structures (Corruccini and Potter 1980; Vig and Fields
2000; Peres et al. 2007; Heimer et al. 2008). Thus, envi-
ronmental factors such as the presence of harmful oral
habits, diet and social characteristics may be related to the
increased prevalence of malocclusion (Chevitarese et al.
2002; Hebling et al. 2008).
Knowledge on the prevalence of malocclusion and
associated factors allows the planning of public health
policies directed at preventing this problem. Since pre-
vention and interventional programmes addressing
123

malocclusion are scarce, especially in young children, it is
important to establish such measures in the realm of public
health (Hebling et al. 2008).
The aim of the present study was to evaluate the prev-
alence of malocclusion and associated factors in the pri-
mary teeth of preschool children in the city of Diamantina,
Brazil.
Materials and methods
A cross-sectional study was carried out in the city of Di-
amantina, which is located in the northern portion of the
state of Minas Gerais in southeast Brazil. Diamantina has a
total of 2,992 children aged 0–4 years. The study popula-
tion was composed of children aged 3–5 years treated at
the 10 basic health care units in the city during immuni-
sation campaigns held in 2010. The vaccination pro-
gramme in Diamantina has coverage rates consistently
surpassing 90 %.
Considering a 75.8 % prevalence rate of malocclusion
(Chevitarese et al. 2002), 95 % confidence interval (CI)
and 5 % standard error, a minimum sample of 288 children
was determined, to which 93 children were added to
compensate for possible losses. Randomisation was per-
formed using systematic sampling. For such, the children
were arranged in a line, with the first child examined, the
second not examined, the third child examined and so on.
Children who did not cooperate during the examination and
those who had abnormal lip and palate were excluded.
Data collection
Data collection involved a clinical oral examination,
anthropometric measurements and a questionnaire admin-
istered in interview form addressing the identification,
socio-demographic factors and general health of the child,
which had been drafted specifically for the present study. A
team made up of three researchers (one examiner and two
assistants) was installed at each of the 10 basic health units,
totalling 30 researchers.
Prior to the fieldwork, the examiners underwent a
training and calibration exercise for the diagnosis of mal-
occlusion. The training exercise was performed using
images of different clinical situations on two separate
occasions with a one-week interval between sessions.
Minimum Kappa values for intra-examiner and inter-
examiner agreement were 0.81 and 0.80, respectively.
A pilot study was conducted with a sample of 30 chil-
dren who were visited at their homes to test and train the
clinical oral examination and data collection method. The
children in the pilot study were not included in the main
study.
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Eur Arch Paediatr Dent
The clinical exam was performed with the aid of dis-
posable tongue depressors and gauze. During the exam, the
child remained seated in a chair in front of the examiner
and a window to make maximal use of natural light. The
procedures complied with biosafety norms.
Anterior open bite was defined as a lack of vertical
overlap between the primary incisors not less than 3 mm
(Katz et al. 2004). Posterior crossbite was defined as a
transverse discrepancy in the relationship between dental
arches, in which the palatal cusps of one or more upper
primary teeth did not occlude in the central fossa of the
lower teeth (Malandris and Mahoney 2004), and was
recorded when at least one upper primary tooth occluded
palatally to the buccal cusp of the lower tooth (Oliveira
et al. 2008a, b; Carvalho et al. 2011). Anterior crossbite
was recorded when a vestibular–lingual alteration was
found in the positioning of the upper and lower incisors,
with an inversion of the occlusion in which the upper
incisor occupied a lingual position in relation to the lower
incisor. Crowding of the dental arches was determined
through an examination of the positioning of the incisal/
occlusal surfaces of the primary teeth.
Anthropometric measures (weight and height) were used
for the assessment of nutritional status. The children were
weighed on a digital scale (Plenna, São Paulo, Brazil); for
such, food intake and the elimination of excrement were
not taken into consideration. Height was determined on a
stadiometer with a millimetre scale and two-metre capacity
(Welmy, Porto Alegre, Brazil) placed on a flat surface.
Nutritional status was determined through comparisons of
the measurements with reference standards stipulated by
the American National Center for Health Statistics (Hamill
et al. 1979).
Information on socio-demographic characteristics
(monthly household income, mother’s schooling and
number of children in the home), age and gender of the
child, presence of harmful oral habits (digit or pacifier
sucking, biting objects and nail biting) and history of
breastfeeding/bottle feeding was collected through
interviews.
Data analysis
Data analysis was performed using the Statistical Package
for Social Sciences (SPSS for Windows, version 17.0,
SPSS Inc. Chicago, IL, USA) and included frequency
distribution and association tests. Associations between the
independent variables and the presence of malocclusion as
well as each type of malocclusion (crowding, crossbite and
open bite) were determined using the Chi square test.
Poisson regression with robust variance was performed for
the analysis of factors associated with malocclusion. The
association magnitude of each factor with the presence of
Eur Arch Paediatr Dent

Table 1 Distribution of
Malocclusion p
malocclusion in primary
dentition of 381 preschool Absent n (%) Present n (%)
children according to aspects
related to child and socio- Gender
demographic factors Male 131 (69.7) 57 (30.3)
Female 126 (65.3) 67 (34.7) 0.360a
Age
36–48 months 110 (62.5) 66 (37.5)
49–60 months 131 (75.7) 42 (24.3)
61–71 months 16 (50.0) 16 (50.0) 0.003a
Health problems
Absent 208 (69.3) 92 (30.7)
Present 48 (60.0) 32 (40.0) 0.144a
Breastfeeding
Absent 14 (45.2) 17 (54.8)
Present 238 (69.0) 107 (31.0) 0.007a
Duration of breastfeeding
B6 months 59 (61.5) 37 (38.5)
[6 months 172 (72.0) 67 (28.0) 0.060a
Bottle feeding
No 122 (77.7) 35 (22.3)
Yes 130 (59.6) 88 (40.4) [0.001a
Child’s nutritional status
Overweight/obesity 15 (51.7) 14 (48.3)
Ideal 221 (71.1) 90 (28.9)
Nutritional risk 16 (59.3) 11 (40.7)
Underweight/very low weight 3 (27.3) 8 (72.7) 0.003b
Harmul oral habits
Absent 170 (33.9) 60 (26.1)
Present 87 (58.0) 63 (42.0) 0.001a
Suction
Absent 224 (72.3) 86 (27.7)
Present 33 (47.1) 37 (52.9) \0.001a
Other habits
Absent 245 (68.8) 111 (31.2)
Present 12 (50.0) 12 (50.0) 0.056a
Number of children
1 or 2 169 (66.0) 85 (34.0)
[2 90 (69.8) 39 (30.2) 0.459a
Household income
B2 times the minimum salary 198 (67.6) 95 (32.4)
[2 times the minimum salary 58 (66.7) 29 (33.3) 0.874a
a
Pearson’s Chi square test Mother’s schooling
(p \ 0.05)
B8 years 163 (69.4) 72 (30.6)
b
Linear trend Chi square test
[8 years 94 (64.4) 52 (35.6) 0.313a
(p \ 0.05)

malocclusion was assessed using non-adjusted and adjusted
prevalence ratios (PR), respective confidence intervals
(CI = 95 %) and p values (Wald test). Explanatory vari-
ables with a p value B0.25 in the bivariate analysis were
incorporated into the model. Thus, all variables were
maintained in the final model, regardless of the p value.
Models were also constructed to determine the association
of each type of malocclusion (crowding, crossbite and open
bite) and the independent variables with a p value B0.25 in
the bivariate analysis. Co-linearity among the independent

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Table 2 Prevalence ratio and confidence interval for associations between malocclusion and associated variables
Variable Prevalence ratio 95 % CI
(unadjusted)
Bottle feeding
Absent – –
Present 1.81 1.297–2.528
Harmful oral habits
Absent – –
Present 1.61 1.208–2.146
variables was determined prior to the construction of the
model.
This study received approval from the Human Research
Ethics Committee of the Federal University of Vales do
Jequitinhonha e Mucuri, Brazil. Parents/guardians signed a
statement of informed consent.
Results
The sample consisted of 381 children aged 3–5 years
(mean: 50.40 ± 8.36 months), corresponding to a response
rate of 98.7 %. Losses were due to lack of data. Among the
children examined, 193 were girls (50.7 %) and 188 boys
(49.3 %). Most children had no harmful oral habits
(60.5 %); 91.8 % had been breastfed and 58.1 % had been
or were currently being bottle fed. Considering socio-
demographic variables, 77.1 % of parents reported a
household income corresponding to two times the Brazilian
minimum salary and most mothers had \8 years of
schooling.
The prevalence of malocclusion was 32.5 %. The most
common type of malocclusion was anterior open bite
(12.3 %), followed by crowding (11.5 %), posterior
crossbite (10.0 %) and anterior crossbite (10.0 %). Mal-
occlusion was more frequent among children aged
61–71 months.
Table 1 displays the associations between malocclusion
and the independent variables. No statistically significant
associations were found between malocclusion and socio-
demographic factors. Regarding aspects related to the
child, nutritional status (p = 0.003), age (p = 0.003), his-
tory of breastfeeding (p = 0.007), history of bottle feeding
(p \ 0.001) and the presence of harmful oral habits
(p = 0.001) were significantly associated with the presence
of malocclusion (Table 1).
In the adjusted multivariate regression (Poisson regres-
sion), a history of bottle feeding (PR 1.74; 95 % CI
1.242–2.449; p = 0.001) and the presence of harmful oral
habits (PR 1.49; 95 % CI 1.123–1.991; p = 0.006)
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p Prevalence ratio 95 % CI p
(adjusted)
– – – –
\0.001 1.74 1.232–2.449 0.001
– – – –
0.001 1.49 1.123–2.449 0.001
remained associated with a greater frequency of maloc-
clusion independently of the other variables (age, health
problems, duration of breastfeeding and nutritional status)
(Table 2).
Table 3 displays the associations between variables
related to the child and each type of malocclusion. Table 4
demonstrates a statistically significant association between
crossbite and mother’s schooling.
In the adjusted multivariate regression, a history of
bottle feeding (PR 5.00; 95 % CI 1.998–12.541;
p = 0.001) and the presence of harmful oral habits (PR
2.902; 95 % CI 1.590–5.294; p = 0.001) remained asso-
ciated with a greater frequency of open bite independently
of the other variables (gender, health problems and dura-
tion of breastfeeding). Moreover, the male gender (PR
1.79; 95 % CI 1.100–2.917; p = 0.019) and mother’s
schooling (PR 1.91; 95 % CI 1.203–3.060; p = 0.006)
remained associated with a greater frequency of crossbite
independently of the other variables (gender, number of
children in home, harmful oral habits) (Table 5).
Discussion
Data collection was conducted during immunisation cam-
paigns in the present study. This is an effective strategy,
especially considering the fact that children in the age
group analysed are generally not in day care centres or
schools, which hinders the location and assessment of this
population (Macena et al. 2009). Another important aspect
regards the fact that children of different socio-economic
levels and areas of the city are found during immunisation
campaigns, which enhances the representativeness of the
sample.
The prevalence of malocclusion was 32.5 %. This rate is
lower than that found in previous studies, which report
rates of 57.6 % in Caucasian children (Tschill et al. 1997)
and 69.9 % in Brazilian preschool children (Kramer et al.
2013). The divergent prevalence rates may be explained by
the use of different diagnostic criteria (Almeida et al.
Eur Arch Paediatr Dent

Table 3 Distribution of malocclusion (crowding, crossbite, open bite) according to aspects related to child (n %)
Variables Crowding Open bite Crossbite
Absent Present Absent Present Absent Present

Gendera
Male 169 (89.9) 19 (10.1) 160 (85.1) 28 (14.9) 167 (88.8) 21 (11.2)
Female 168 (87.0) 25 (13.0) 174 (90.2) 19 (9.8) 156 (80.8) 37 (19.2)
p value 0.385 0.134 0.030
Age (months)b
36–48 152 (86.4) 24 (13.6) 150 (85.2) 26 (14.8) 148 (84.1) 28 (15.9)
49–60 157 (90.8) 16 (9.2) 158 (91.3) 15 (8.7) 151 (87.3) 22 (12.7)
61–71 28 (87.5) 4 (12.5) 26 (81.2) 6 (18.8) 24 (75.0) 8 (25.0)
p value 0.450 0.584 0.666
Health problemsa
No 270 (90.0) 30 (10.0) 265 (88.3) 35 (11.7) 255 (85.0) 45 (15.0)
Yes 66 (82.5) 14 (17.5) 68 (85.0) 12 (15.0) 67 (83.8) 13 (16.2)
p value 0.062 0.421 0.782
c
Breastfeeding
No 30 (96.8) 1 (3.2) 22 (71.0) 9 (29.0) 20 (64.5) 11 (35.5)
Yes 302 (87.5) 43 (12.5) 307 (89.0) 38 (11.0) 298 (86.4) 47 (13.6)
p value 0.153 0.008 0.003
Duration of breastfeedinga
B6 months 81 (84.4) 15 (15.6) 77 (80.2) 19 (19.8) 82 (85.4) 14 (14.6)
[6 months 212 (88.7) 27 (11.3) 222(92.9) 17 (7.1) 207 (86.6) 32 (13.4)
p value 0.279 0.001 0.774
Bottle feedinga
No 140 (89.2) 17 (10.8) 152 (96.8) 5 (3.2) 137 (87.3) 20 (12.7)
Yes 191 (87.6) 27 (12.4) 177 (81.2) 41 (18.8) 181 (83.0) 37 (17.0)
p value 0.644 \0.001 0.260
Nutritional statusb
Overweight/obesity 27 (93.1) 2 (6.9) 22 (75.9) 7 (24.1) 22 (75.9) 7 (24.1)
Ideal 275 (88.4) 36 (11.6) 280 (90.0) 31 (10.0) 268 (86.2) 43 (13.8)
Nutritional risk 25 (92.6) 2 (7.4) 21 (77.8) 6 (22.2) 23 (85.2) 4 (14.8)
Underweight/low weight 7 (63.6) 4 (36.4) 8 (72.7) 3 (27.3) 8 (72.7) 3 (27.3)
p value 0.057 0.444 1.0
Habitsa
No 202 (87.8) 28 (12.2) 215 (93.5) 15 (6.5) 199 (86.5) 31 (13.5)
Yes 134 (89.3) 16 (10.7) 118 (78.7) 32 (21.3) 124 (82.7) 26 (17.3)
p value 0.654 \0.001 0.304
a
Pearson’s Chi square test
b
Linear trend Chi squared test
c
Fisher Exact test—p \ 0.05

2008). The present study only included the evaluation of
open bite, crossbite and crowding. Overjet and overbite
were not considered, as observed in previous studies
(Carvalho et al. 2011). The major problem in evaluating
malocclusion in preschool children regards the lack of
measures that specifically assess malocclusion traits in
primary teeth (Abanto et al. 2011). Thus, differences in the
evaluation of malocclusion in preschoolers could be
minimised by the development and validation of assess-
ment tools designed for the primary dentition.
The prevalence of malocclusion was higher among
children who were not breastfed and among those who
were bottle fed. The type of feeding affects craniofacial
development. Breastfeeding provides the intense exercise
of orofacial muscles and contributes to adequate dentofa-
cial development (Caglar et al. 2005). In contrast, the use

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Table 4 Distribution of malocclusion (crowding, crossbite, open bite) according to socio-demographic factors
Variables Crowding Open bite Crossbite
Absent Present Absent Present Absent Present

Mother’s schooling
B8 years 207 (88.1) 28 (11.9) 204 (86.8) 31 (13.2) 208 (88.5) 27 (11.5)
[8 years 130 (89.0) 16 (11.0) 130 (89.0) 16 (11.0) 115 (78.8) 31 (21.2)
p value 0.777 0.519 0.010
Number of children
1 or 2 221 (88.4) 29 (11.6) 219 (87.6) 31 (12.4) 206 (82.4) 44 (17.6)
[2 114 (88.4) 15 (11.6) 113 (87.6) 16 (12.4) 115 (89.1) 14 (10.9)
p value 0.994 0.999 0.084
Household income
B2 times the minimum salary 258 (88.1) 35 (11.9) 255 (87.0) 38 (13.0) 252 (86.0) 41 (14.0)
[2 times the minimum salary 78 (89.7) 9 (10.3) 78 (89.7) 9 (10.3) 70 (80.5) 17 (19.5)
p value 0.062 0.514 0.206

Table 5 Prevalence ratio and confidence interval for associations between malocclusion (open bite and crossbite) and associated variables
Dependent Independent Prevalence ratio 95 % CI p Prevalence 95 % CI p
variable variable (unadjusted) ratio (adjusted)

Open bite Bottle feeding

Absent – – – – – –
Present 5.91 0.06–.42 \0.001 4.14 0.09–0.62 0.003
Sucking habits
Absent – – – – – –
Present 5.02 0.11–.35 \0.001 3.95 0.14–0.45 \0.001
Crossbite Gender
Male 1.71 0.34–0.99 \0.001 1.79 0.32–0.95 0.033
Female – – – – –
Mother’s schooling
B8 years 1.84 0.32–0.90 0.020 1.91 0.31–0.87 0.013
[8 years –

of the bottle requires less effort for a child to feed, does not
provide the emotional pleasure related to suckling, can
impair dentofacial development and can lead to the
installation of harmful habits, such as sucking on pacifiers,
fingers and objects (Mizuno and Ueda 2006).
Harmful oral habits were significantly associated with
malocclusion in the present investigation, which is in
agreement with the findings reported in previous studies
(Bishara et al. 2006; Scavone et al. 2007). Non-nutritive
sucking habits are related to the development of posterior
crossbite (Scavone et al. 2007; Macena et al. 2009; Hebling
et al. 2008) as well as open bite (Hebling et al. 2008),
which are the most common types of malocclusion found
in children. Thus, harmful oral habits may be risk factors or
factors associated with malocclusion in children. However,
it should be noted that the presence of such habits does not
necessarily indicate that a child will develop malocclusion.
The frequency, intensity and duration of the habit (Graber’s
triad) and the facial growth of each child should be taken
into consideration (Wood 1962; Hebling et al. 2008).
Nutritional status has been associated with oral health
(Oliveira et al. 2008a, b; Thomaz and Valença 2009) and
protein-energy malnutrition is associated with the impaired
growth and development of facial bones (Thomaz et al.
2010). This effect is expressed in a reduction in the length
of the skull base, height of the mandible, width of the
maxilla and mandible and height of the lower third of the
face as well as dental and skeletal ages (Thomaz and
Valença 2009). It has therefore been suggested that mal-
nutrition is associated with malocclusion (Almeida et al.
2008; Thomaz and Valença 2009). The present findings
lend support to this hypothesis, as statistically significant
associations were found between nutritional status and
malocclusion. Moreover, the prevalence of malocclusion

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was higher among children with low or very low body
mass based of the classification of nutritional status
(Hamill et al. 1979).
The present investigation has the limitations of any
cross-sectional study: it is only possible to establish asso-
ciations between factors and malocclusion, but no causal
relationships can be determined. Thus, longitudinal studies
are needed to allow the follow up of the development of
malocclusion, comparing children exposed to the factors
determined in the present study to those not exposed to
such factors.
Information on factors that may predispose children to
malocclusion is of particular importance to the formulation
of preventive strategies and the early diagnosis of maloc-
clusion. Besides the presence of harmful oral habits, factors
such as breastfeeding and nutritional status should also be
considered. Guidelines for parents regarding the impor-
tance of breastfeeding and the assessment of nutritional
status constitute a valid approach to general health and
other oral problems besides malocclusion in preschool
children.
Conclusion
Based on the present findings, malocclusion is more com-
mon among preschool children with a history of bottle
feeding and those with harmful oral habits, such as non-
nutritive sucking.
Conflict of interest The authors declare that they have no conflict
of interest.
References
Abanto J, Carvalho TS, Mendes FM, et al. Impact of oral diseases and
disorders on oral health-related quality of life of preschool
children. Commun Dent Oral Epidemiol. 2011;39:105–14.
Almeida ER, Narvai PC, Frazão P, Guedes-Pinto AC. Revised criteria
for the assessment and interpretation of occlusal deviations in the
deciduous dentition: a public health perspective. Cad Saude
Publica. 2008;24:897–904.
Bishara SE, Warren JJ, Broffitt B, Levyd SM. Changes in the
prevalence of nonnutritive sucking patterns in the first 8 years of
life. Am J Orthod Dentofac. 2006;130:31–5.
Caglar E, Larsson E, Andersson EM, et al. Feeding, artificial sucking
habits, and malocclusions in 3-year-old girls in different regions
of the world. J Dent Child. 2005;72:25–30.
Carvalho AC, Paiva SM, Scarpelli AC, et al. Prevalence of
malocclusion in primary dentition in a population-based sample
of Brazilian preschool children. Eur Dent Paediatr Dent.
2011;12:107–11.
Chevitarese AB, Della Valle D, Moreira TC. Prevalence of maloc-
clusion in 4–6 year old Brazilian children. J Clin Pediatr Dent.
2002;27:81–5.
Corruccini RS, Potter RH. Genetic analysis of occlusion variation in
twins. Am J Orthod. 1980;78:140–54.
Cunningham SJ, Hunt NP. Quality of life and its importance in
orthodontics. J Orthod. 2001;28(2):152–8.
Dhar V, Van Jain A, Dyke TE, Kohli A. Prevalence of gingival
diseases, malocclusion and fluorosis in school-going children of
rural areas in Udaipur district. J Indian Soc Pedod Prev Dent.
2007;25:103–5.
Hamill PVV, Drizd TA, Johnson CL, et al. Physical growth: National
Center for Health Statistics percentiles. Am J Clin Nutr.
1979;32:607–29.
Hebling SRF, Cortellazzi KL, Tagliferro EPS, et al. Relationship
between malocclusion and behavioral, demographic and socio-
economic variables: a cross-sectional study of 5-year-olds. J Clin
Pediatr Dent. 2008;33:75–80.
Heimer MV, Tornisiello Katz CR, Rosenblatt A. Non-nutritive
sucking habits, dental malocclusions, and facial morphology in
Brazilian children: a longitudinal study. Eur J Orthod.
2008;30:580–5.
Katz CR, Rosenblatt A, Gondim PP. Nonnutritive sucking habits in
Brazilian children: effects on deciduous dentition and relation-
ship with facial morphology. Am J Orthod Dentofacial Orthop.
2004;126:53–7.
Kramer PF, Feldens CA, Helena Ferreira S, et al. Exploring the
impact of oral diseases and disorders on quality of life of
preschool children. Community Dent Oral Epidemiol. 2013 Jan
21 [Epub ahead of print].
Leite-Cavalcanti A, Medeiros-Bezerra PK, Moura C. Breast-feeding,
bottlefeeding, sucking habits and malocclusion in Brazilian
preschool children. Rev Salud Publica. 2007;9:194–204.
Liu Z, McGrath C, Hägg U. The impact of malocclusion/orthodontic
treatment need on the quality of life: a systematic review. Angle
Orthod. 2009;79:585–91.
Macena MC, Katz CR, Rosenblatt A. Prevalence of a posterior
crossbite and sucking habits in Brazilian children aged
18–59 months. Eur J Orthod. 2009;31:357–61.
Malandris M, Mahoney EK. Aetiology, diagnosis and treatment of
posterior cross-bites in the primary dentition. Int J Paediatr Dent.
2004;14:155–66.
Marques LS, Barbosa CC, Ramos-Jorge ML, Pordeus IA, Paiva SM.
Malocclusion prevalence and orthodontic treatment need in
10–14-year-old schoolchildren in Belo Horizonte, Minas Gerais:
a psychosocial focus. Cad Saude Publica. 2005;21:1099–106
[Article in Portuguese].
Mizuno K, Ueda A. Changes in sucking performance from nonnu-
tritive sucking to nutritive sucking during breast- and bottle-
feeding. Pediatr Res. 2006;59:728–31.
Oliveira AC, Paiva SM, Campos MR, Czeresnia D. Factors associated
with malocclusions in children and adolescents with Down
syndrome. Am J Orthod Dentofacial Orthop. 2008;133:489.e1–8.
Oliveira LB, Sheiham A, Bönecker M. Exploring the association of
dental caries with social factors and nutritional status in
Brazilian preschool children. Eur J Oral Sci. 2008;116:37–43.
Peres KG, Barros AJ, Peres MA, Victora CG. Effects of breastfeeding
and sucking habits on malocclusion in a birth cohort study. Rev
Saude Publica. 2007;41:343–50.
Scavone H Jr, Ferreira RI, Mendes TE, Ferreira FV. Prevalence of
posterior crossbite among pacifier users: a study in the deciduous
dentition. Braz Oral Res. 2007;21:153–8.
Thomaz EBAF, Valença AMG. Relationship between childhood
underweight and dental crowding in deciduous teething. J Pedi-
atr. 2009;85:110–6.
Thomaz EB, Cangussu MC, da Silva AA, Assis AM. Is malnutrition
associated with crowding in permanent dentition? Int J Environ
Res Public Health. 2010;7:3531–44.
123
 Eur Arch Paediatr Dent

Tschill P, Bacon W, Sonko A. Malocclusion in the deciduous WHO: oral health surveys—basic methods. 4th edn. Geneva: World
dentition of Caucasian children. Eur J Orthod. 1997;19:361–7. Health Organization, 1997.
Vig KW, Fields HW. Facial growth and management of orthodontic Wood AWS. Anterior and posterior crossbites. J Dent Child.
problems. Pediatr Clin North Am. 2000;47:1085–123. 1962;29:280–6.

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