Originl Article Desire for orthodontic tretment nd ssocited fctors mong dolescents in southern Brzil Crlos Alberto Feldens ; Edurdo Kenji Nkmur b ;Fábio Rfel Tessrollo c ; Lucine Qudrdo Closs b ABSTRACT Objective: To estimte the prevlence of the desire for orthodontic tretment nd investigte ssocited fctors mong dolescents in southern Brzil. Mterils nd Methods: A cross-sectionl study ws crried out with 704 dolescents ged 12 nd 13 yers t municipl public schools in the city of Blneário Cmboriú (southern Brzil). The dolescents nswered previously tested questionnire ddressing stisfction with their dentl ppernce, speech function, chewing function, nd the desire for orthodontic tretment. The prents/gurdins nswered questionnire ddressing stisfction with their child s dentl ppernce nd socioeconomic vribles. A trined nd clibrted orthodontist collected clinicl dt on mlocclusion using the Dentl Aesthetic Index (DAI). Sttisticl nlysis ws performed using multivrite Poisson regression with robust vrince. Results: The prevlence of the desire for orthodontic tretment ws 69.6% (490/704). In the djusted nlysis, the outcome ws significntly more prevlent mong girls (P,.001), those with difficulty chewing (P 5.026), those disstisfied with their dentl ppernce (P,.001), nd those with greter mlocclusion severity (P,.001). The following orthodontic chrcteristics were ssocited with the desire for orthodontic tretment in the multivrite model: distem in nterior segment (P,.001), nterior mxillry irregulrity (P,.001), mxillry overjet $6 mm(p,.001), nd mndibulr overjet (P 5.047). Conclusions: The desire for orthodontic tretment mong 12- nd 13-yer-old dolescents is influenced by gender, disstisfction with one s dentl ppernce, difficulty chewing, mlocclusion severity, nd orthodontic chrcteristics. These findings should be considered together with normtive indictions regrding the need for orthodontic tretment in dolescents. (Angle Orthod. 2015;85:224 232.) KEY WORDS: Orthodontics; Mlocclusion; Desire; Motivtion INTRODUCTION The impct of mlocclusion on qulity of life hs been the object of study in different popultions. 1 6 Prticulr types of mlocclusion seems to ffect Professor, Deprtment of Peditric Dentistry, School of Dentistry, Universidde Lutern do Brsil, Cnos, Brzil. b Professor, Deprtment of Orthodontics, School of Dentistry, Universidde Lutern do Brsil, Cnos, Brzil. c Lecturer, Deprtment of Orthodontics, Instituto de Odontologi ds Américs, Blneário Cmboriú, Brzil. Corresponding uthor: Dr Crlos Alberto Feldens, Ru João Telles 185/1301, Porto Alegre, Rio Grnde do Sul 90.035-121, Brzil (e-mil: cfeldens@terr.com.br) Accepted: My 2014. Submitted: Februry 2014. Published Online: July 21, 2014 G 2015 by The EH Angle Eduction nd Reserch Foundtion, Inc. stisfction with one s dentl ppernce, fcil ppernce, generl ppernce, nd perceived ttrctivness. 2,7 9 The high prevlence rtes in different popultions demonstrte tht mlocclusion is public helth problem tht requires the plnning nd implementtion of intervention strtegies. 10,11 While orthodontic tretment is n effective mnner to tret different types of mlocclusion 12,13 nd cn led to n improvement in qulity of life, 4,13,14 the desire to undergo tretment hs been explored little in the scientific literture. This desire seems to be influenced by socil nd culturl chrcteristics in different popultions 15 18 s well s gender, self-perceived esthetics nd function, 1,19 21 nd mlocclusion severity. 7,17,22,23 However, few studies hve investigted the joint influence of these chrcteristics in dolescents. The motivtions of dolescents nd their prents regrding orthodontic tretment seem to contribute to 224 DOI: 10.2319/021014-105.1
DESIRE FOR ORTHODONTIC TREATMENT IN ADOLESCENTS 225 coopertion during tretment, the prognosis of the cse, nd posttretment stisfction. 20,24,25 Thus, orthodontists nd dministrtors of helthcre services should recognize this network of interreltions with the im of chieving fvorble outcome for the ptient s well s improving the cost effectiveness of the services offered. The ims of the present study were to explore the demogrphic nd socioeconomic fctors s well s the perceptions of dolescents nd their prents ssocited with the desire for orthodontic tretment mong 12- nd 13-yer-old dolescents in southern Brzil nd identify the orthodontic chrcteristics ssocited with this outcome. MATERIALS AND METHODS Subjects nd Study Design The present cross-sectionl study ws prt of lrger study evluting the prevlence of mlocclusion nd ssocited fctors mong dolescents in southern Brzil. The investigtion received pprovl from the Humn Reserch Ethics Committee of the Universidde Lutern. The prents/gurdins of the dolescents signed sttement of informed consent. In ddition, n ffirmtive greement to prticipte in reserch ws obtined from ll dolescents. The source popultion consisted of individuls ged 12 nd 13 yers enrolled t ll of the municipl eduction centers (n 5 11) in the city of Blneário Cmboriú, which hs popultion of 100,000 nd is locted in the stte of Snt Ctrin. The inclusion criterion ws ge 12 or 13 yers, s this is the ge t which the permnent dentition is estblished, when most subjects cn be evluted using the Dentl Aesthetic Index (DAI), nd it is lso the most dequte period for beginning orthodontic tretment. Adolescents in the mixed dentition phse nd those with history of orthodontic tretment were excluded from the study. The clcultion of the smple size ws bsed on source popultion of 1200 schoolchildren, n estimted 30% prevlence rte of mlocclusion, 95% confidence level, n 80% power, nd 2.5% mrgin of error. These prmeters determined minimum smple of 622 dolescents. Estimting 30% nonresponse rte nd the exclusion of 10% of the dolescents due to history of orthodontic tretment, questionnires were delivered to ll 12- nd 13-yerold students t ll schools in the city. Questionnires The dolescents nswered structured questionnire ddressing sex, ge, perceptions of dentl ppernce, speking function, nd chewing function. This questionnire employed five-point rting scle (very poor/poor/fir/good/very good) nd ws bsed on previously used dt collection instrument. 26,27 Disstisfction with one s dentl ppernce, speking function, nd chewing function ws then dichotomized (yes 5 poor or very poor; no 5 fir, good or very good).the dolescents lso nswered question tht corresponded to the outcome of the study: Would you like to undergo orthodontic tretment? (no/yes). The questions were first dministered to 35 students in pilot study on two occsions with 2-week intervl. Relibility ws determined using the kpp sttistic, which demonstrted nerly perfect reproducibility for the five-point scle (k 5 0.87; 95% CI: 0.77 0.96) nd perfect reproducibility for the outcome question (k 5 1.00). The prents/gurdins nswered structured questionnire ddressing socioeconomic sttus (bsed on the mother s schooling) nd stisfction with their child s dentl ppernce. Clinicl Exm The clinicl exm ws performed by n experienced orthodontist using mouth mirror, guze, wooden tongue depressor, nd periodontl probe (Community Periodontl Index) 28 following biosfety norms. Ethnicity nd orthodontic chrcteristics (bsed on the DAI 29 recommended by the World Helth Orgniztion 28 ) were recorded on ech individul s clinicl chrt. The DAI involves the evlution of 10 prmeters of dentofcil nomlies relted to clinicl nd rdiogrphic spects: missing teeth, crowding of the nterior segment, spcing in the nterior segment, distem in the nterior segment, lrgest nterior mxillry irregulrity, lrgest nterior mndibulr irregulrity, nterior mxillry overjet, nterior mndibulr overjet, nterior open bite, nd nteroposterior molr reltionship. Bsed on these, DAI llows the ctegoriztion of norml occlusion or minor mlocclusion (#25), definite mlocclusion with elective tretment need (26 to 30), severe mlocclusion with highly desirble tretment need (31 to 35), nd hndicpping mlocclusion for which tretment is required ($36). Intrexminer relibility ws tested in pilot study involving 20 12- nd 13-yer-old students exmined on two occsions with 2-week intervl between exmintions. The men kpp coefficient ws 0.86. Sttisticl Anlysis Dt nlysis ws performed using the Sttisticl Pckge for the Socil Sciences (SPSS, version 16.0, Chicgo, Ill). The chi-squre test nd Poisson regression with robust vrince were used to test the
226 FELDENS, NAKAMURA, TESSAROLLO, CLOSS Figure 1. Flow digrm t ech stge of recruiting study prticipnts. strength of the ssocitions between the outcome (desire for orthodontic tretment) nd demogrphic vribles, socioeconomic vribles, dolescent s perception of his/her dentl ppernce, prents stisfction with their child s dentl ppernce, nd the DAI. In the crude model, seprte prevlence rtios nd 95% confidence intervls were estimted for the independent vribles. The multivrite model begn with ll co-vribles, which were successively eliminted (bckwrd stepwise procedure) bsed on the lrgest P vlue (Wld test). Only vribles with P vlue,.05 remined in the model. A new model ws then run to investigte ssocitions between orthodontic chrcteristics (DAI) nd the outcome. Univrite nd multivrite Poisson regression with robust vrince ws performed following the sme criteri in the previous nlysis. Missing teeth ws the only orthodontic chrcteristic not included s n independent vrible due to the low frequency of subjects with missing teeth in the smple. The level of rejection of the null hypothesis ws set to 5% (P,.05). RESULTS The finl smple consisted of 704 dolescents. Figure 1 shows the flowchrt of the study. Similr distribution ws found for gender (mle: 53.1%; femle: 46.9%) nd ge (12 yers: 45.6%; 13 yers: 54.4%). Most subjects were white (75.3%) followed by brown (18.7%), nd blck (6.0%). Mother s schooling rnged from 0 to 13 yers (men [SD]: 7.5 [3.3] yers). The distribution of DAI scores ws pproximtely symmetricl nd rnged from 13 to 47 (men [SD]: 53.3 [5.8] points; medin [P25 P75]: 24 [21 28] points). The prevlence of the desire for orthodontic tretment ws 69.6% (490/704) nd ws significntly higher mong dolescents with greter mlocclusion severity (P,.001) (Tble 1). Moreover, the outcome ws significntly more prevlent mong femle dolescents (P,.001), those with difficulty chewing (P 5.007), those disstisfied with their dentl ppernce (P 5.003), nd those whose prents were disstisfied with their child s dentl ppernce (P,.001). A significnt positive correltion ws found between prents nd dolescents perception with dentl ppernce (P,.001; Spermn r 5 0.161). The prevlence of prents stisfction with their child s dentl ppernce decresed with the increse in mlocclusion severity from 73.8% (norml or minor mlocclusion) to 48.9% (hndicpping mlocclusion) (chi-squre test for liner trend: P,.001, not in Tble).
DESIRE FOR ORTHODONTIC TREATMENT IN ADOLESCENTS 227 Tble 1. Desire for Orthodontic Tretment According to Independent Vribles Vribles N (%) Desire for Orthodontic Tretment n (%) Totl 704 (100.0) 490 (69.6) P Sex.000 Mle 374 (53.1) 239 (63.9) Femle 330 (46.9) 251 (76.1) Age, y.291 12 321 (45.6) 217 (67.6) 13 383 (54.4) 273 (71.3) Ethnicity.113 Blck 42 (6.0) 24 (57.1) White 530 (75.3) 378 (71.3) Brown 132 (18.7) 88 (66.7) Mother s schooling, y.471,5 176 (25.1) 128 (72.7) 5 8 291 (41.5) 202 (69.4).8 234 (33.4) 157 (67.1) Difficulty chewing.007 Yes 153 (21.7) 120 (78.4) No 551 (78.3) 370 (67.2) Difficulty speking.093 Yes 77 (10.9) 60 (77.9) No 627 (89.1) 430 (68.6) Disstisfction with dentl ppernce.003 Yes 133 (18.9) 107 (80.5) No 571 (81.1) 383 (67.1) Prents stisfction with child s dentl ppernce Yes 470 (66.8) 295 (62.8).000 No 234 (33.2) 195 (83.3) DAI b.000 #25 (norml or minor mlocclusion) 413 (58.7) 253 (61.3) 26 30 (definite mlocclusion) 169 (24.0) 130 (76.9) 31 35 (severe mlocclusion) 77 (10.9) 66 (85.7) $36 (hndicpping mlocclusion) 45 (6.4) 41 (91.1) Chi-squre test. b DAI indictes Dentl Aesthetic Index. In the crude model, the sme vribles were ssocited with the outcome (Tble 2). After the multivrite djustments, the desire for orthodontic tretment ws greter mong femle dolescents (PR: 1.18; 95% CI: 1.07 1.30), mong those who reported difficulty chewing (PR: 1.12; 95% CI: 1.01 1.24), nd mong those who were disstisfied with their dentl ppernce (PR: 1.15; 95% CI: 1.04 1.27). Moreover, the desire for orthodontic tretment ws significntly greter in ll ctegories of mlocclusion: 25% greter mong those with n elective tretment need (PR: 1.25; 95% CI: 1.12 1.39), 38% greter mong those with severe mlocclusion (PR: 1.38; 95% CI: 1.23 1.55), nd nerly 50% greter mong those with very severe to debilitting mlocclusion (PR: 1.49; 95% CI: 1.32 1.69). Prents disstisfction with their child s dentl ppernce lost its sttisticl significnt fter the multivrite djustments. Regrding orthodontic vribles (Tble 3), the outcome ws significntly ssocited with crowding (P 5.036), distem in the nterior segment (P 5.008), nterior mxillry irregulrity (P,.001), mxillry overjet (P 5.003), nd bnorml molr reltionship (P 5.002). In the multivrite nlysis (Tble 4), the desire for orthodontic tretment ws greter mong those with distem of 1 mm in the nterior segment (PR: 1.24; 95% CI: 1.07 1.44), mong those with distem $2 mm in the nterior segment (PR: 1.34; 95% CI: 1.14 1.57), mong those with lrgest nterior mxillry irregulrity between 1 nd 2 mm (PR: 1.13; 95% CI: 1.01 1.26), mong those with lrgest nterior mxillry irregulrity $3 mm (PR: 1.48; 95% CI: 1.31
228 FELDENS, NAKAMURA, TESSAROLLO, CLOSS Tble 2. Crude nd Adjusted Prevlence Rtios (PR) nd 95% Confidence Intervls (95% CI) for Desire for Orthodontic Tretment According to Independent Vribles Crude Model Adjusted Model Vribles PR (95% CI) P PR (95% CI) P Sex.000.000 Mle 1.00 1.00 Femle 1.19 (1.08 1.31) 1.18 (1.07 1.30) Age, y.294 12 1.00 # 13 1.05 (0.95 1.16) Ethnicity.183 Blck 1.00 # White 1.25 (0.95 1.63) Brown 1.17 (0.87 1.56) Mother s schooling, y.460,5 1.08 # 5 8 1.03 (0.95 1.23).8 1.00 (0.92 1.16) Difficulty chewing.003.026 Yes 1.17 (1.05 1.29) 1.12 (1.01 1.24) No 1.00 1.00 Difficulty speking.054 Yes 1.14 # No 1.00 (1.00 1.29) Disstisfction with dentl ppernce.000.000 Yes 1.20 (1.08 1.33) 1.15 (1.04 1.27) No 1.00 1.00 Prents stisfction with child s dentl ppernce.000 Yes 1.00 # No 1.33 (1.21 1.45) DAI b.000.000 #25 (norml or minor mlocclusion) 1.00 1.00 26 30 (definite mlocclusion) 1.26 (1.12 1.41) 1.25 (1.12 1.39) 31 35 (severe mlocclusion) 1.40 (1.24 1.58) 1.38 (1.23 1.55) $36 (hndicpping mlocclusion) 1.49 (1.32 1.68) 1.49 (1.32 1.69) # indictes vribles not in finl model. b DAI indictes Dentl Aesthetic Index. 1.66), mong those with mxillry overjet $6 mm (PR: 1.29; 95% CI: 1.11 1.49), nd mong those with mndibulr overjet $1 mm (PR: 1.32; 95% CI: 1.01 1.73). The molr reltionship lost is sttisticl significnce fter the djustments for the other orthodontic vribles. No significnt differences were found between respondents nd nonrespondents regrding gender (femle respondents: 46.9%; femle nonrespondents: 48.2%; P 5.655) or schooling (men [SD] schooling mong respondents: 6.6 [1.0] yers; men [SD] schooling mong nonrespondents: 6.5 [0.9] yers; P 5.083). DISCUSSION The indiction for orthodontic tretment hs historiclly been bsed on exclusively normtive spects perceived by orthodontists with the im of chieving n idel occlusion. 30,31 However, ptients re incresingly exposed to externl motivtions regrding tretment, such s pressure from fmily nd friends s well s wht is considered cceptble in their socil surroundings. 20,22,32 These spects, long with internl motivtion relted to the ptient s self-perception nd the extent to which tretment is desired, hve often been relegted to bckground position. 16,33 The min finding of the present study is tht more thn two thirds of the dolescents wished to undergo orthodontic tretment, independently of their socioeconomic sttus, ge, nd ethnic group. This desire ws greter mong femle dolescents nd those with negtive perception regrding their dentl ppernce nd chewing function. Moreover, distem in the nterior segment, nterior mxillry irregulrity, nd
DESIRE FOR ORTHODONTIC TREATMENT IN ADOLESCENTS 229 Tble 3. Desire for Orthodontic Tretment According to Dentl Aesthetic Index Components Desire for Orthodontic Tretment Vribles N (%) n (%) P Crowding.036 No 251 (35.7) 168 (66.9) 1 Segment 214 (30.4) 141 (65.9) 2 Segments 239 (33.9) 181 (75.7) Spcing in nterior segment.943 No 496 (70.5) 345 (69.6) 1 Segment 135 (19.2) 95 (70.4) 2 Segments 73 (10.3) 50 (68.5) Distem in nterior segment, mm.008 0 624 (88.6) 424 (67.9) 1 46 (6.5) 37 (80.4) $2 34 (4.8) 29 (85.3) Lrgest irregulrity in mxill, mm.000 0 335 (47.6) 217 (64.8) 1 to 2 330 (46.9) 236 (71.5) $3 39 (5.5) 37 (94.9) Lrgest irregulrity in mndible, mm.157 0 308 (43.8) 208 (67.5) 1 to 2 376 (53.4) 265 (70.5) $3 20 (2.8) 17 (85.0) Mxillry overjet, mm.003,2 154 (21.9) 106 (68.8) 2 to 5 489 (69.5) 330 (67.5) $6 61 (8.7) 54 (88.5) Mndibulr overjet.290 b No 695 (98.7) 482 (69.4) $1 mm 9 (1.3) 8 (88.9) Anterior open bite No 690 (98.0) 478 (69.3) Yes 14 (2.0) 12 (85.7) Molr reltionship.002 Norml 290 (41.2) 187 (64.5) Difference of ½ cusp 210 (29.8) 145 (69.0) Difference of $1 cusp 204 (29.0) 158 (77.5) Chi-squre test. b Fisher exct test..248 b mxillry nd mndibulr overjet were lso ssocited with the desire for tretment. These findings indicte tht subjective nd orthodontic chrcteristics perceived by the ptient re importnt fctors for orthodontists to tke into considertion nd underscore the importnce of investigting spects relted to internl motivtion during the initil ppointment. 16,20,33 Filing to consider the ptient s desire nd internl motivtions for correction hinders the estblishment of prognosis for ech cse nd increses the likelihood of lesser coopertion during tretment or even the bndonment of tretment. 25 Moreover, if the source of motivtion is predominntly externl, the ptient is less likely to be stisfied t the end of tretment. 24,25 The fct tht femle dolescents hve greter desire for orthodontic tretment hs been reported in previous studies. 9,18,19 Nonetheless, there is no consensus in the literture on this gender issue, since some studies hve found no such ssocition, 7,10,17,34 Differences in the trits nd even rights of ech gender vry cross cultures. However, it is generlly recognized tht women seek tretment more nd re more self-criticl regrding their ppernce, which underlines the plusibility of the ssocition detected in the present study. 16,19,34,35 The stisfction of dolescents with their dentl nd fcil ppernce hs been reported to be ssocited with the desire for orthodontic tretment in different popultions. 7,21,23,36 Orl helth professionls generlly recognize tht esthetic issues re prepondernt mong internl motivtions for tretment. 7,17,19 21,36,37 However, the subjectivity involved in self-perceived
230 FELDENS, NAKAMURA, TESSAROLLO, CLOSS Tble 4. Crude nd Adjusted Prevlence Rtios (PR) nd 95% Confidence Intervls (95% CI) for Desire for Orthodontic Tretment According to Dentl Aesthetic Index Components Crude Model Adjusted Model Vribles PR (95% CI) P PR (95% CI) P Crowding.029 No 1.00 1 Segment 0.98 (0.86 1.12) # 2 Segments 1.13 (1.01 1.27) Spcing in nterior segment.961 No 1.00 1 Segment 1.01 (0.89 1.14) # 2 Segments 0.98 (0.83 1.16) Distem in nterior segment, mm.002,.001 0 1.00 1.00 1 1.18 (1.02 1.38) 1.24 (1.07 1.44) $2 1.25 (1.08 1.46) 1.34 (1.14 1.57) Lrgest irregulrity in mxill, mm.000,.001 0 1.00 1.00 1 to 2 1.10 (0.99 1.22) 1.13 (1.01 1.26) $3 1.46 (1.31 1.63) 1.48 (1.31 1.66) Lrgest irregulrity in mndible, mm.077 0 1.00 1 to 2 1.04 (0.94 1.15) # $3 1.26 (1.03 1.53) Mxillry overjet, mm.000,.001,2 1.00 1.00 2 to 5 0.98 (0.87 1.11) 1.02 (0.90 1.15) $6 1.29 (1.12 1.48) 1.29 (1.11 1.49) Mndibulr overjet.039 No 1.00 1.00 $1 mm 1.28 (1.01 1.62) 1.32 (1.01 1.73).047 Anterior open bite.057 No 1.00 # Yes 1.24 (0.99 1.54) Molr reltionship.005 Norml 1.00 Difference of ½ cusp 1.07 (0.94 1.21) # Difference of $1 cusp 1.20 (1.07 1.34) # indictes vribles not in finl model. esthetics nd ppernce indictes the need for discussion of these concepts mong the orthodontist, ptient, nd fmily during the initil ppointment. In the present study, the desire for tretment ws more prevlent mong dolescents with perception of poor chewing function. While most previous investigtions hve not reported n ssocition between n improvement in chewing function nd the desire for orthodontic tretment, Li et l. 38 found positive ssocition between these vribles. These findings demonstrte tht esthetic spects re not the only reson why dolescents seek tretment. It is interesting to note tht n orthodontic chrcteristic tht chrcterizes normtive dignosis, nmely the molr reltionship, ws not ssocited with the desire for tretment nd generlly does not constitute n importnt spect in the ptient s perception of tretment need. In contrst, other orthodontic chrcteristics ssocited with the desire for correction distem in the nterior segment, lrgest nterior mxillry irregulrity, mxillry overjet, nd mndibulr overjet re objective spects tht require specil ttention on the prt of the orthodontist with regrd to the dignosis t the end of tretment. Moreover, s these conditions re chrcterized by frequent relpses, there is need for dequte retention following the ctive tretment phse, s stisfction with tretment is relted to the mintennce of the results chieved. 39 The present study hs limittions tht should be ddressed. The DAI cn underestimte the occurrence
DESIRE FOR ORTHODONTIC TREATMENT IN ADOLESCENTS 231 of mlocclusion, s it does not mesure crossbite or symmetry nd midline devition. However, this index hs been incorported into the Interntionl Collbortion Study of Orl Helth Outcomes of the World Helth Orgniztion 28 nd hs been widely employed in epidemiologic studies. 3,40 Selection bis is unlikely to hve occurred in this study. Despite the impossibility of estimting the desire for tretment mong nonrespondents, the uthors do not believe this spect mde significnt difference, s the bseline chrcteristics of the respondents nd nonrespondents were very similr. Another spect ws the smll number of questions for the detection of disstisfction with one s dentl ppernce nd orl functions s well s the nswers obtined with the use of scles nd subsequently dichotomized s yes nd no. Nonetheless, despite not being previously vlidted, the dt collection instruments demonstrted excellent reproducibility nd enbled the evlution of lrge smple of subjects, providing more ccurte estimtes of the reltionship between the perceptions of dolescents nd their prents regrding the desire for orthodontic tretment. The present findings cn be generlized to popultions with similr demogrphic nd culturl chrcteristics to the popultion tht lives in southern Brzil: predominntly white with heterogeneous socioeconomic sttus nd living in developing country. CONCLUSIONS N The prevlence of the desire for orthodontic tretment ws high in the popultion studied, with higher rtes found mong femle dolescents, those with severe mlocclusion, nd those with poor perception of their dentl ppernce nd chewing function. N The orthodontic chrcteristics ssocited with desire for orthodontic tretment were distem in the nterior segment, nterior mxillry irregulrity, mxillry overjet, nd mndibulr overjet. 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