Journal of the World Federation of Orthodontists 1 (2012) e67ee72

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Research

Prevalence and gender comparison of malocclusion among Japanese

adolescents: A population-based study
Yuko Komazaki a, b, Takeo Fujiwara b, *, Takuya Ogawa a, c, d, Miri Sato e, Kohta Suzuki e, Zentaro Yamagata f,
Keiji Moriyama a, c, d
a
Department of Maxillofacial Orthodontics, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
b
Department of Social Medicine, National Research Institute for Child Health and Development, Tokyo, Japan
c
Global Center of Excellence program for Molecular Science for Tooth and Bone Diseases, Tokyo Medical and Dental University, Tokyo, Japan
d
Hard Tissue Genome Research Center, Tokyo Medical and Dental University, Tokyo, Japan
e
Center for Birth Cohort Studies, Interdisciplinary Graduate School of Medicine and Engineering, University of Yamanashi, Yamanashi, Japan
f
Department of Health Sciences, Interdisciplinary Graduate School of Medicine and Engineering, University of Yamanashi, Yamanashi, Japan

a r t i c l e i n f o a b s t r a c t

Article history: Background: A lack of studies regarding the prevalence of malocclusion, including gender comparisons,
Received 11 January 2012 has precluded an efficient dental health policy in Japan. We aimed to describe the prevalence and
Received in revised form perform a gender comparison of malocclusion requiring orthodontic treatment in Japan.
10 May 2012
Methods: On the basis of the index of orthodontic treatment need, occlusal characteristics of a pop-
Accepted 3 July 2012
ulation-based sample of adolescents (ages 12e15 years) were evaluated by orthodontists.
Available online 6 August 2012
Results: A total of 821 adolescents participated in this study. The prevalence of malocclusion was 46.5%.
Multivariate logistic regression indicated that girls were 1.56 times more likely than boys to develop
Keywords:
Gender comparison
malocclusion, particularly with anterior crossbite and upper and lower crowding.
Index of orthodontic treatment need (IOTN) Conclusions: This population-based study revealed that approximately half of the Japanese adolescents
Japan included in this study had malocclusion, which occurred primarily in girls. This study may provide
Malocclusion reliable baseline data regarding the orthodontic treatment needs of the Japanese adolescent population.
Prevalence Ó 2012 World Federation of Orthodontists.

1. Introduction prevalence of malocclusion in Japan by using the index of ortho-

To quantify orthodontic treatment needs, a number of epide-
miological studies have been performed to determine the preva-
lence of malocclusion in various ethnic groups, including
Caucasians [1,2], non-Hispanic blacks [3e6], and non-Hispanic
whites [5]. Because malocclusion is the most common dentofacial
anomaly that varies considerably according to the population in
question [6,7], it is necessary to establish an efficient dental health
policy and training program for specialists in Japan to assess the
prevalence of malocclusion requiring orthodontic treatment among
the current population.
Few studies have investigated the prevalence of malocclusion
among Asians, including the Japanese. Two studies investigated the
Conflict of Interest: The authors have no conflicts of interest to declare.
* Corresponding author: Department of Social Medicine, National Research
Institute for Child Health and Development, 2-10-1 Okura, Setagaya-ku, Tokyo 157-
8535, Japan.
E-mail address: fujiwara-tk@ncchd.go.jp (T. Fujiwara).
dontic treatment need (IOTN) [8] and found prevalence rates of
35.5% [9] and 56% [10]. However, these studies did not include
population-based samples. Therefore, it was necessary to investi-
gate the prevalence of malocclusion requiring orthodontic treat-
ment based on internationally comparable diagnostic criteria in
a representative sample among junior high school students, most of
who have permanent dentition and have not undergone treatment
for their malocclusion.
To identify adolescents at high risk of developing malocclusion
and to thereby develop an efficient dental health policy, there is
a need to clarify the gender differences related to malocclusion risk
in a given population. However, previous reports of gender differ-
ences related to malocclusion prevalence are inconclusive. In Italy,
adolescent boys ages 11 to 14 years are more likely to develop either
increased overbite or overjet [11]. However, other studies have re-
ported no gender differences among adolescents in Columbia [12],
France [13], Latvia [14], Norway [15], and the United Kingdom [16].
To the best of our knowledge, only a few studies have compared the
prevalence of malocclusion between genders in Japan [9,10].

2212-4438/$ e see front matter Ó 2012 World Federation of Orthodontists.

http://dx.doi.org/10.1016/j.ejwf.2012.07.001
e68 Y. Komazaki et al. / Journal of the World Federation of Orthodontists 1 (2012) e67ee72

Thus, we aimed to investigate the prevalence and perform
a gender comparison of malocclusion requiring orthodontic treat-
ment among Japanese adolescents by using a population-based
sample and internationally comparable diagnostic criteria.
2. Materials and methods
(n ¼ 141), and who did not have information regarding their
treatment history (n ¼ 1) were excluded. Koshu City is the field
study area for Project Koshu, an ongoing prospective birth-cohort
study that began in 1988 [17].
This study was approved by the ethical review board of Tokyo
Medical and Dental University (No. 619) and the University of
Yamanashi, School of Medicine (No. 332).

2.1. Patients
The present study included all of the students enrolled in every
junior high school (school n ¼ 5) in Koshu City (ages 12e15 years;
students n ¼ 991). The students who were absent on the exami-
nation day (n ¼ 28), who had received orthodontic treatment
2.2. Measurement of occlusal traits
This study was conducted within a general health checkup in the
junior high schools that all of the adolescents were supposed to
receive. The participants were examined using portable lighting

Table 1
Definition of malocclusion requiring treatment

Characteristic Treatment need Borderline to none Definition Measurement method

1 Increased overjet
2 Reverse overjet
3 Deep bite
4 Open bite
5 Posterior crossbite
6 Anterior crossbite
7 Lingual crossbite
8 Crowding
9 Cleft lip and/or palate
10 Hypodontia
Overjet > 6 mm Overjet  6 mm Increased overjet was defined if overjet Overjet was defined as the horizontal
was > 6 mm. overlap of the incisors.
Overjet < e1 mm Overjet  e1 mm Reverse overjet was defined if the It was measured using a periodontal
overjet was < e1 mm. probe from the labial surface of the
most anterior lower central incisor to
the labial surface of the most anterior
upper central incisor parallel to the
occlusal plane.
All the measurements were made to the
nearest 0.5 mm.
Patients with restorations on the
central incisors were excluded.
Overbite > 5 mm Overbite  5 mm Deep bite was defined if overbite Overbite was defined as the vertical
was > 5 mm. overlap of the incisors.
Overbite < e4 mm Overbite  e4 mm Open bite was defined if overbite It was measured using a periodontal
was > e4 mm. probe between the level of the edge
of the upper central incisor and the
lower central incisor.
All the measurements were made to the
nearest 0.5 mm.
Patients with restorations on central
incisor were excluded.
(þ) (e) Posterior crossbite was registered if one Direct observation of the premolars/
or more maxillary premolars/molars molars.
lingually occluded the mandibular
premolars/molars.
(þ) (e) Anterior crossbite was registered if one Direct observation of the incisors/
or more maxillary incisors/canines canines.
lingually occluded the mandibular
incisors/canines.
(þ) (e) Lingual crossbite was recorded when Direct observation of the premolars/
lingual cusps of one or more molars.
maxillary molars buccally occluded
the buccal surfaces of corresponding
mandibular teeth.
Crowding  5 mm Crowding  4 mm Crowding  5 mm in each jaw was Crowding was recorded in the maxillary
registered. and mandibular arches separately
and was graded by inspection as
follows:
0. None
1. Crowding  4 mm
2. 5 mm  crowding  9 mm
3. 10 mm  crowding
Spacing was also recorded.
(þ) (e) Defects of cleft lip and/or palate. Direct observation of the lip and palate.
(þ) (e) Hypodontia was registered. Direct observation of the dentition.
a) extensive hypodontia with
restorative implications (more than
one tooth missing in any quadrant)
requiring prerestorative orthodontics
b) less extensive hypodontia requiring
prerestorative orthodontics or
orthodontic space closure to obviate
the need for a prosthesis (not more
than one tooth missing in any
quadrant)
 Y. Komazaki et al. / Journal of the World Federation of Orthodontists 1 (2012) e67ee72
while sitting on a chair. Angle’s classification, posterior and anterior
crossbite, lingual crossbite, upper and lower crowding, dental age,
cleft lip and/or palate, hypodontia, and median diastema were
examined using a dental mirror. Overjet, overbite, midline discrep-
ancy, and tooth size of the upper left central incisor were measured
using periodontal probes (YDM Ltd., Tokyo, Japan). Orthodontic
treatment history was also obtained from the participants. Because
this study was conducted within a general health checkup in the
junior high schools, radiographs, study casts, or previously written
records of the participants were not included in our analysis.
2.3. Evaluation of malocclusion
The IOTN is composed of two components [8], the dental health
component (DHC) [18] and the aesthetic component (AC) [19]. In
this study, we utilized only the DHC to diagnose malocclusion
because the DHC and AC are highly correlated [9] and the DHC is
more reliable than the AC as a measure of malocclusion [13].
Furthermore, the time allocated for dental examination was very
limited (1e2 min per person), as this study was conducted within
the framework of a general health checkup. For the same reason,
the details of three IOTN definitions were slightly modified. One is
deep bite, which was defined as increased and complete overbite
causing notable indentations on the palate or labial gingivae in the
IOTN, which was defined as >5 mm in this study. The second
definition was for anterior and posterior crossbite, which we
defined regardless of displacement between retruded contact
position and intercuspal position (as shown in the Table 1), while
the IOTN defines anterior and posterior crossbite as >2 mm
displacement between retruded contact position and intercuspal
position. The final definition was for reverse overjet, which was
defined as less than e3.5 mm with no reported masticatory or
speech difficulties or e3.5 mm < overjet < e1 mm with reported
masticatory or speech difficulties; the IOTN defined reverse overjet
as less than e1 mm with no reported masticatory or speech diffi-
culties. The details of the criteria used in this study for the evalu-
ation of malocclusion are described in Table 1.
The dental examinations were performed by three orthodontists
from the same department (Section of Maxillofacial Orthognathics,
Tokyo Medical and Dental University). These orthodontists had
completed more than 2 years of training and were educated in the
same graduate school (Section of Maxillofacial Orthognathics,
Tokyo Medical and Dental University). Kappa statistics between the
three orthodontists were satisfactory for inter-rater reliability
(k ¼ 0.58, 96.0% agreement).
2.4. Statistical analysis
The occlusal traits of the boys and girls included in this study were
compared using the chi-square test for categorical variables and
either the t test or Wilcoxon rank-sum test for continuous variables
(i.e., midline discrepancy and tooth size) based on their distribution.
The midline discrepancy values were not normally distributed,
whereas the tooth size data were normally distributed. The odds ratio
(OR) for each item to diagnose malocclusion and malocclusion
requiring treatment in girls were calculated using bivariate and
multivariate logistic regression adjusted for grade (i.e., age), and
tooth size. The significance level was set at 0.05. Stata 12 SE (Stata-
Corp LP, College Station, TX) was used for all statistical analyses.
3. Results and discussion
The present study was implemented as part of a school-based
health checkup and all students, except those absent from the
school on the day of the checkup, participated in the study (n ¼ 963,
e69
Table 2
Participant characteristics by treatment history (n ¼ 962)
Treatment Treatment P for
history e history þ chi-square
(n ¼ 821) (n ¼ 141) test
n % n %
Sex
Boys 455 55.4 59 41.8 0.003
Girls 366 44.6 82 58.2
Grade
1 259 31.5 40 28.4 0.75
2 299 36.4 53 37.6
3 263 32.0 48 34.0
97.2%). The percentage of the population with an orthodontic
treatment history was 14.6% (n ¼ 141 [59 boys and 82 girls); this
percentage was higher among girls than boys (18.3% vs. 11.5%;
P ¼ 0.003). Thus, by excluding those who had previously received
orthodontic treatment (n ¼ 141) and who did not have information
regarding treatment history (n ¼ 1), the final sample included 821
adolescents (82.8% of all of the junior high school students in Koshu
City [n ¼ 991]). The distributions of gender and grade level are
presented in Table 2. In Japan, grade 1 includes adolescents ages 12
to 13 years, grade 2 consists of ages 13 to 14 years, and grade 3
includes ages 14 to 15 years. All students were Japanese.
Table 3 shows the distribution of occlusal traits. The mean
tooth size was 8.58 mm (standard deviation, 0.024); moreover, the
tooth size was larger in boys than that of girls (8.68 mm vs.
8.44 mm; P < 0.001). The prevalence of anterior crossbite was
18.6%, which was higher in girls than that of boys (23.2% vs. 15.0%;
P ¼ 0.002). The prevalence of upper crowding 5 mm was 18.7%,
which was higher in girls than that of boys (23.2% vs. 15.2%;
P ¼ 0.001). The prevalence of malocclusion requiring orthodontic
treatment was 46.5% (95% confidence interval [CI], 43.0e49.9),
which was higher in girls (51.4%; 95% CI, 46.2e56.5) than boys
(42.5%; 95% CI, 37.9e47.1).
Table 4 depicts the ORs for girls having each item included in the
diagnosis of malocclusion and malocclusion requiring treatment.
According to the crude model, girls were more likely than boys to
develop anterior crossbite (OR, 1.72; 95% CI, 1.21e2.45), upper
crowding (OR, 1.69; 95% CI, 1.19e2.41), and malocclusion requiring
treatment (OR, 1.43; 95% CI, 1.08e1.88). After adjusting for grade
(model 1), similar ORs were obtained, thus suggesting that grade was
less likely to confound the association between gender and maloc-
clusion. Further adjustment for tooth size (model 2) revealed that girls
were more likely than boys to develop anterior crossbite (OR,1.90; 95%
CI, 1.32e2.74) and upper crowding (OR, 1.80; 95% CI, 1.25e2.59). In
addition, lower crowding became significant (OR, 1.66; 95% CI,
1.07e2.57). Finally, girls were 1.56 times more likely to develop
malocclusion requiring treatment than boys (95% CI, 1.17e2.07).
This study found that the prevalence of malocclusion requiring
orthodontic treatment among Japanese adolescents was 46.5%
(i.e., almost half of the adolescents needed orthodontic treatment).
In addition, girls were 1.56 times more likely than boys to develop
malocclusion, particularly anterior crossbite, upper crowding, and
lower crowding after adjusting for grade and tooth size.
In a previous Japanese study using the IOTN, the prevalence of
malocclusion among adolescents ages 11 to 14 years was 35.5% [9].
The higher prevalence observed in our study was likely due to the
lack of functional evaluation and the differences in sample compo-
sition (i.e., a higher participation rate in our study). Another study,
which included casts for evaluations, reported a malocclusion
prevalence of 56.0% [10]; the higher prevalence reported by the
previous study was most likely attributable to a higher overall
sample age (participants ages 15e18 years) than that of our study.
e70 Y. Komazaki et al. / Journal of the World Federation of Orthodontists 1 (2012) e67ee72

Table 3
Distribution of occlusal traits and malocclusion requiring treatment (n ¼ 821)

All (n ¼ 821) Boys (n ¼ 455) Girls (n ¼ 366) P for chi-square test

n or mean % or SD n or mean % or SD n or mean % or SD

Occlusal traits not used for diagnosis
Angle (right)
Class I 482 58.9 268 59.0 214 58.8 0.93
Class II 234 28.6 128 28.2 106 29.1
Class III 102 12.5 58 12.8 44 12.1
Angle (left)
Class I 454 55.5 258 56.8 196 53.9 0.14
Class II 285 34.8 159 35.0 126 34.6
Class III 79 9.7 37 8.2 42 11.5
Angle
Class I 372 51.3 204 51.5 168 51.1 0.62
Class II division 1 134 18.5 70 17.7 64 19.5
Class II division 2 54 7.5 28 7.1 26 7.9
Class II (not division 1 or 2) 89 12.3 55 13.9 34 10.3
Class III 76 10.5 39 9.9 37 11.3
Median diastema
(þ) 24 2.9 14 3.1 10 2.7 0.77
(-) 797 97.1 441 96.9 356 97.3
Dental age
III B 133 16.2 90 19.8 43 11.8 0.004
III C 261 31.8 146 32.2 115 31.4
IV A 426 52.0 218 48.0 208 56.8
Midline discrepancy (mm) 1.11 0.041 1.02 0.051 1.21 0.065 0.022*
Tooth size (mm) 8.58 0.024 8.68 0.033 8.44 0.034 < 0.001y
Occlusal traits used for diagnosis
Overjet
> 6 mm 80 9.8 42 9.2 38 10.4 0.48z
1 to 6 mm 730 89.0 409 89.9 321 88.0
< e1 mm 10 1.2 4 0.9 6 1.6
Overbite
> 5 mm 73 8.9 39 8.6 34 9.3 0.45z
4 to 5 mm 743 90.6 415 91.2 328 89.9
< e4 mm 4 0.5 1 0.2 3 0.8
Posterior crossbite
(þ) 58 7.1 27 6.0 31 8.5 0.16
(e) 761 92.9 426 94.0 335 91.5
Anterior crossbite
(þ) 153 18.6 68 15.0 85 23.2 0.002
(e) 668 81.4 387 85.1 281 76.8
Lingual crossbite
(þ) 28 3.4 15 3.3 13 3.6 0.84
(e) 793 96.6 440 96.7 353 96.5
Upper spacingx 96 11.7 67 14.7 29 7.9 0.001z
Upper crowdingx
None 268 32.6 161 35.4 107 29.2
 4 mm 303 36.9 158 34.7 145 39.6
5e9 mm 121 14.7 53 11.7 68 18.6
 10 mm 33 4.0 16 3.5 17 4.6
Lower spacingx 57 7.0 36 7.9 21 5.8 0.21z
Lower crowdingx
None 263 32.1 155 34.1 108 29.6
 4 mm 400 48.8 216 47.5 184 50.4
5e9 mm 89 10.9 44 9.7 45 12.3
 10 mm 11 1.3 4 0.9 7 1.9
Cleft lip and/or palate
(þ) 0 0.0 0 0.0 0 0.0 NA
(e) 821 100.0 455 100.0 366 100.0
Hypodontia
(þ) 0 0.0 0 0.0 0 0.0 NA
(e) 821 100.0 455 100.0 366 100.0
Diagnosed malocclusion
Malocclusion requiring treatmentjj
(þ) 381 46.5 193 42.5 188 51.4 0.011
(e) 439 53.5 261 57.5 178 48.6

NA, not applicable; SD, standard deviation.

* Wilcoxon rank-sum test was performed.
y
A t test was performed.
z
Fisher’s exact test was performed.
x
Spacing and crowding (upper/lower) were combined to calculate P value.
jj
Malocclusion requiring treatment was defined as overjet > 6 mm or < e1 mm, overbite > 5 mm or < e4 mm, posterior or anterior crossbite, lingual crossbite, upper or
lower crowding > 4 mm, cleft of lip and/or palate, or hypodontia.
 Y. Komazaki et al. / Journal of the World Federation of Orthodontists 1 (2012) e67ee72 e71

Table 4
Odds ratio of gender difference for items used to diagnose malocclusion and malocclusion requiring treatment (n ¼ 821)

Crude Model 1 Model 2

OR 95% CI OR 95% CI OR 95% CI

Increased overjet
Girl 1.14 (0.71e1.81) 1.12 (0.71e1.78) 1.08 (0.67e1.73)
Boy Reference Reference Reference
Reverse overjet
Girl 1.88 (0.53e6.73) 1.77 (0.49e6.34) 2.50 (0.67e9.35)
Boy Reference Reference Reference
Deep bite
Girl 1.10 (0.68e1.77) 1.12 (0.69e1.82) 1.10 (0.67e1.80)
Boy Reference Reference Reference
Open bite
Girl 3.76 (0.39e36.3) 3.29 (0.34e32.0) 3.23 (0.31e33.2)
Boy Reference Reference Reference
Posterior crossbite
Girl 1.46 (0.85e2.49) 1.48 (0.87e2.54) 1.50 (0.87e2.58)
Boy Reference Reference Reference
Anterior crossbite
Girl 1.72 (1.21e2.45) 1.70 (1.19e2.42) 1.90 (1.32e2.74)
Boy Reference Reference Reference
Lingual crossbite
Girl 1.08 (0.51e2.30) 1.04 (0.49e2.23) 1.13 (0.52e2.45)
Boy Reference Reference Reference
Upper crowding
Girl 1.69 (1.19e2.41) 1.68 (1.18e2.40) 1.80 (1.25e2.59)
Boy Reference Reference Reference
Lower crowding
Girl 1.41 (0.93e2.14) 1.39 (0.91e2.12) 1.66 (1.07e2.57)
Boy Reference Reference Reference
Clefts of lip and/or palate
Girl N/A N/A N/A
Boy Reference Reference Reference
Hypodontia
Girl N/A N/A N/A
Boy Reference Reference Reference
Malocclusion which needs treatment
Girl 1.43 (1.08e1.88) 1.43 (1.08e1.88) 1.56 (1.17e2.07)
Boy Reference Reference Reference

Model 1 adjusted for grade.

Model 2 adjusted for grade, and tooth size.
Bolds indicates P < 0.05.
CI, confidence interval; OR, odds ratio; N/A, not applicable.

Several studies have reported the prevalence of occlusal traits
in diverse populations, and the variability of the results of these
studies is likely due to the differences in ethnicity, registration
methods, and sample composition [12,20]. Previous studies re-
ported that Japanese adolescents are more likely to develop
malocclusion than Nigerian, Australian, Chinese, and white
American adolescents, according to the dental aesthetic index
[6,7]. Other studies using the IOTN in the United Kingdom re-
ported that one-third of 12-year-old adolescents require ortho-
dontic treatment [16,21], which is lower than the percentage
observed in our study conducted in Japan. Another study using the
IOTN on 12-year-old children in the United Kingdom found that
the prevalence of increased overjet was 8.8%, the prevalence of
reverse overjet (less than e1 mm) was 2.2%, and that of crowding
was 8.9% [22]. Similarly, a study using the IOTN for French children
ages 9 to 12 years reported that the prevalence of increased overjet
was 4.3%, the prevalence of reverse overjet (less than e1 mm) was
1.3%, and that of crowding was 4.3%. However, an Italian study
including adolescents ages 11 to 14 years that did not utilize the
IOTN reported that the prevalence of increased overjet (> 5 mm)
was 6.5%, the incidence of reverse overjet (< 0 mm) was 1.1%, and
that of crowding (> 3 mm) was 20.2% [11]. A comparison of these
previous studies with our findings (increased overjet, 9.8%; reverse
overjet, 1.2%; crowding, 23.7%) suggests that Japanese adolescents
are more likely to develop increased overjet and crowding than
European adolescents, whereas reverse overjet has a similar
prevalence. These observed differences might be due to genetic or
environmental factors [23]. The higher prevalence of crowding
among Japanese might be explained by the observation that Asians
are more likely than other populations to have brachycephalic
skulls [24]. The higher prevalence of increased overjet among
Japanese might be because Asians are more likely to have shovel-
shaped upper incisors than whites [25]. Further studies are needed
to elucidate the differences in the prevalence of malocclusion
among various ethnic groups.
We found a higher prevalence of malocclusion in girls than that
of boys. This finding is inconsistent with data from studies con-
ducted in Europe or Latin America, which reported no gender
differences in the malocclusion prevalence [12e16]. An Italian
study reported that boys are more likely to have increased overjet
or overbite among white adolescents ages 11 to 14 years [11].
However, we found that girls are more likely to develop an anterior
crossbite and upper and lower crowding; the differences in our
results might be explained by ethnic differences. Japanese girls are
more likely to have smaller jaws than boys, while this is not the case
for whites. In contrast, white boys are more likely to have increased
overbite or overjet than girls; however, this observation is not true
for Japanese boys.
The possible factors that contribute to the higher prevalence of
anterior crossbite and upper and lower crowding in Japanese girls
than that of boys might be the sizes of the maxilla and mandible,
and not tooth size. In this study, the mean tooth size of girls was
e72 Y. Komazaki et al. / Journal of the World Federation of Orthodontists 1 (2012) e67ee72
smaller than that of boys (8.68 mm vs. 8.44 mm; P < 0.001), and the
addition of tooth size as a confounding variable (model 2) increased
the ORs. This finding suggests that tooth size inversely influenced
the association between gender and malocclusion. A possible
reason for this may be the smaller jaws of girls than those of boys
[26,27]. Furthermore, a genetic study of malocclusion suggested the
etiology of crowding in girls [28]. Single nucleotide polymorphisms
(SNPs) in the EDA and XEDAR genes that are located on the X
chromosome were associated with dental crowding in the Hong
Kong Chinese population, thus suggesting that the incidence of
crowding in girls is affected by SNPs. In addition, the higher prev-
alence of crowding in girls might be explained by the larger leeway
space observed in girls [29]. However, gender differences in the
leeway space mainly occurred due to the differences of the size of
the permanent second premolars [29]. Thus, the differences in the
prevalence of anterior crossbite may not be fully explained by the
gender differences observed in the leeway space. Further studies
are required to elucidate the factors that contribute to the higher
prevalence of crowding in Japanese girls.
Our study has several study limitations. First, some participants
still had their primary second molars because the study population
included adolescents ages 12 to 15 years. Thus, crowding might be
overestimated since the leeway space was not considered during the
evaluation of the degree of crowding. Second, the prevalence of
malocclusion might be underestimated because we excluded
students who had received orthodontic treatment from our analyses.
Third, this study was conducted within the framework of a general
health checkup in the junior high schools, thus a full functional
evaluation was not conducted. Fourth, our sample included adoles-
cents ages 12 to 15 years and mandibular growth occurs as children
age, which might induce reverse overjet and anterior or posterior
crossbite. On the other hand, mandibular growth might improve
increased overjet. Although both scenarios are possible in theory, the
prevalence of malocclusion in adolescents ages 12-15 years in this
study cannot be overestimated because the majority of malocclusion
diagnoses included other conditions than increased overjet (79%).
Finally, as this was a cross-sectional study, the causality of maloc-
clusion cannot be solely attributed to gender-related genetic factors;
other factors such as genetic factors, the duration of breast feeding,
pacifier sucking, thumb sucking, or dental caries might directly
induce the development of malocclusion [30,31]. Further studies that
include various genetic and environmental factors are needed to
clarify the etiology of malocclusion.
The results of this study indicated that school dentists should
identify adolescents who require orthodontic treatment on the
basis of the IOTN (a useful screening tool for assessing the status of
malocclusion) and refer them to orthodontists. The results ob-
tained in this study provide reliable baseline data for planning
orthodontic services within the existing public dental health
system in Japan.
4. Conclusions
The prevalence of malocclusion in Japan was relatively high (1 in
2), and girls were 1.56 times more likely to develop malocclusion
requiring treatment. The factors that contribute to the higher
prevalence of malocclusion among girls require further elucidation
for the prevention of malocclusion in the future.
Acknowledgments
We would like to thank all of the study participants, school staff,
and school dentists of the junior high schools of Koshu City; and the
staff of the Section of Maxillofacial Orthognathics. This study was
conducted with the cooperation of dentists of the Yamanashi
Dental Association, and was supported by a grant for the Japan
Environment & Children’s Study (PI: Dr Hiroshi Sato).
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