Françeska Vinjolli¹, Evisi Nastasi², Sara Ghanim³, Arianna Malara^4*, Ines Nurja⁵, Paola Cozza⁶, Giuseppina Laganà⁷

¹Department of Medical Science, Catholic University Our Lady of Good Counsel, 1000 Tirana, Albania

²Private Orthodontic Practice, 69-71 Banbury Road, Oxford, United Kingdom

³Private Practice, Albania and Italy

⁴Department of Surgical Science, Catholic University Our Lady of Good, Counsel, 1001 Tirana, Albania

⁵Department of Economics and Finance, University of New York, Tirana, Albania

⁶Unicamillus Saint Camillus International University of Health Sciences Rome, Italy

⁷Department of Life Sciences, Health and Healthcare Professions, Link Campus University, 00165 Rome, Italy

^*Corresponding Author: Arianna Malara, Department of Surgical Science, Catholic University Our Lady of Good, Counsel, 1001 Tirana, Albania

Received: 27 April 2025; Accepted: 09 May 2025; Published: 19 June 2025

Article Information

Citation: Françeska Vinjolli, Evisi Nastasi, Sara Ghanim, Arianna Malara, Ines Nurja, Paola Cozza, Giuseppina Laganà. Prevalence of Malocclusions and Oral habits in a preschool Albanian children population: A cross-sectional study. Dental Research and Oral Health. 8 (2025): 65-74.

DOI: 10.26502/droh.0093

Abstract

Keywords

Epidemiological study, Malocclusions, Oral habits, Nonnutritive sucking, Pediatric orthodontics, Early intervention

Article Details

Introduction

Malocclusion is a disorder of the craniofacial complex that affects physiological conditions by disrupting the development of the dental and maxillofacial regions, as well as masticatory function [1]. To effectively prevent and manage different malocclusions, it is essential to know their prevalence in the society. Numerous studies have investigated the prevalence of malocclusions in primary dentition across various countries and groups, revealing prevalence rates between 21.0% to 88.1% [2-9]. Epidemiological studies are essential for delivering comprehensive data on a population's health, allowing each nation to formulate targeted public health initiatives [10,11]. Many Authors indicate that specific primary occlusion traits and anomalies are frequently manifested in or even intensified by the permanent dentition, owing to the impact of primary dentition on the permanent occlusion developing process [12]. Persistent non-nutritive sucking practices beyond the initial three years of life are often correlated with posterior crossbite and anterior open bite [12].

Diastemas in the anterior region, normal overbite and overjet, a straight or mesial step molar connection, and Class I canine relationship are good indicators of favorable development of permanent occlusion. Pacifier use and digit or thumb sucking are prevalent soothing activities, particularly among infants. These actions are usually termed "non-nutritive sucking habits" and their impact on the development of dental malocclusion is unquestionable [13].

Many Authors indicate that oral habits and mouth breathing grow more common with the increasing severity of malocclusion. Furthermore, anterior open bite, posterior crossbite, and increased overjet are significantly correlated with oral habits and mouth breathing [14,15].

Albania lacks national oral health surveys or studies regarding the prevalence of malocclusion in preschool children.

Therefore, this epidemiological study aims to evaluate the prevalence of malocclusions, oral habits, and their correlation within a preschool-aged Albanian population.

Materials and Methods

Study Design and Population Selection

A multistage, stratified sampling approach was employed to obtain a representative sample of preschool-aged children across eight districts (Tirana, Shkoder, Durres, Vlore, Kruje, Elbasan, Pogradec, and Korce) in Albania. These districts were selected using probability proportional to size (PPS) sampling to ensure adequate representation of varying socio-economic conditions. The final study cohort comprised n. 1.213 children (628 males, 585 females) aged 3 to 6 years, mean age of 4.65 years, recruited from 20 kindergartens in alignment with the World Health Organization’s basic methods for oral health surveys [16]. To be eligible for inclusion, children were required to have a complete set of primary canines and second molars, with no history of dental anomalies, orthodontic treatment, syndromes or craniofacial anomalies.

Written informed consent was obtained from the parents or legal guardians prior to the clinical examination of every child. The study protocol was approved by the Ethical Committee of the Catholic University "Our Lady of Good Counsel" Tirana, Albania (Approval No. 251/2023).

Clinical Examination

The orthodontic assessment was conducted by three expert examiners (F.V.,E.N., S.G.) who completed a training program in orthodontic diagnosis prior to data collection. The training emphasized the methodology to perform a comprehensive clinical examination specifically designed for young children. To ensure diagnostic accuracy and standardization of procedures. the examiners participated in a pilot study involving 60 children before the main investigation. Statistical analysis revealed no significant differences in the results from the pilot study (P > 0.05), indicating the consistency and reliability of the examination process.

A registration chart was developed for each participant, incorporating an anamnestic questionnaire (Figure 1) which provided pertinent information regarding the oral habits of every child, inquiring about pacifier use, digit sucking, oral breathing, and bruxism and clinical oral examination measurements, with the exclusion of radiographic imaging.

Additional questions were included regarding the duration of these habits, as prolonged habits tend to have a more severe impact on dentition.

The oral examination (Figure 2), conducted in adherence to the World Health Organization (WHO) guidelines [16], was performed within an approximate duration of about 10 minutes per child. Examinations were carried out during the school year 2023-2024, on-site at the kindergarten, facilitating accessibility for preschool-aged participants and the following parameters were recorded:

• • Sagittal anomalies:Canine and molar relationships (Class I, II, III)
• • Vertical anomalies:Overbite, anterior open bite
• • Transversal anomalies:Posterior crossbite, midline displacement
• • Space discrepancies:Crowding, spacing

Statistical method

All collected data were entered into a Microsoft Excel program, from where they were then exported to SPSS (IBM SPSS Statistics, NY, USA) 27.0, a program in which all statistical analysis was performed. The analysis performed was descriptive and consisted of generating frequency tables, cross-tabulations and percentages and inferential data. The variables were created based on the studies’ criteria, and their distribution across the entire population was considered.

Figure 1: Anamnestic Questionnaire including details on child's oral habits.

Figure 2: Clinical oral examination including the intraoral and extraoral analysis.

Results

The distribution of the examined sample is presented in table 1: most participants reside in Tirana, the largest city in Albania.

Table 1: Regional distribution of normal occlusion and malocclusion in various urban centers.

The allocation of subjects according to malocclusion type is presented in table 2. At least one issue in the sagittal, vertical, or transverse plane was identified to determine the presence of malocclusion. The frequency of malocclusion exhibits little gender variation, however significant differences are observed across various age groups. Malocclusions were observed in 52% of the sample. Malocclusions were observed in 52% of the sample.

Table 2: Descriptive analyses of demographic characteristics of the sample.

Table 3 displays the prevalence of sagittal abnormalities. which indicates that class II malocclusion is the most prevalent in the sample under investigation. Specifically, 19.1% of cases are classified in the canine Class II and 19% in the second molar class (distal step). Normal occlusion was observed in 76.8% of the canine class I and 77.2% of the molar class I, vertical terminal plane, 1.6% of the subjects exhibited canine Class III, while 1.5% of the subjects exhibited molar Class III (mesial advance).

Table 3: Composition and prevalence of sagittal occlusal characteristics.

Furthermore. 2.4% of the sample exhibited asymmetric malocclusion. The overjet and anterior crossbite were also assessed on the sagittal plane, with a 19.43% increased overjet and a 6.8% reduced overjet. Anterior cross bite was observed in 1.4% of the cases.

Table 4 offers a comprehensive summary of the space characteristics. as well as the issues in the vertical and transversal dimensions. Deep bite is the most prevalent issue in the vertical plane. afflicting 21.4% of participants. The proportion of subjects with an open bite has increased from three to six years, representing 4.6% of all cases. There was a statistically significant difference in the distribution of various overbite. The transversal problems associated with lateral crossbite with and without shift are 2.2% and 1.7%, respectively. The most prevalent issue in the transversal plane is the absence of midline coincidence, which occurs in 9.5% of cases and has a heightened tendency to occur during growth. Furthermore, age-related classic diastemas are present in 91.4% of patients, while 6.4% have dental crowding.

Table 4: Composition and prevalence of vertical. transversal and space occlusal characteristics.

The questionnaires assessed the presence of oral habits, with responses provided by parents for 543 subjects, representing 44.7% of the total sample. The most prevalent oral habits reported by parents in the questionnaire that was administered prior to the clinical assessment are summarized in table 5, classified by gender. Pacifier feeding was the most prevalent non-nutritive habit in this study group. and it was discontinued by 36 months of age. Teeth clenching and mouth breathing were the next most common non-nutritive habits observed. Thumb suckling, an additional non-nutritive habit that was observed in this sample, is also prevalent during the first three years of life and is only rarely observed after this age.

Table 5: Composition and prevalence of oral habits.

The correlation between the most prevalent oral habits and occlusal traits is illustrated in table 6. There is a significant correlation between oral respiration and open bite.

No significant correlations were discovered between occlusal characteristics and other oral habits.

CCII- canine class II. CCIII-canine class III. Ovj-overjet. Ovb- overbite. UPC -unilateral posterior crossbite. BPC-Bilateral posterior crossbite

1. No statistics are computed because CrossbiteLateralConShift is a constant.

Table 6: Correlation between oral habits and occlusal traits.

Discussion

The purpose of the present study was to evaluate the prevalence of malocclusion and oral behaviors in a cohort of children aged 3 to 6 years attending kindergartens throughout Albania. Tirana, the capital of the nation, is home to a substantial number of the study participants and has the highest population density. The research provides a comprehensive examination of the prevalence and distribution of malocclusion in various urban areas, demographic groups. and types of occlusions.

In Albania, this is the first nationwide investigation that has specifically addressed this age group, to the best of our knowledge.

Kongo et al. conducted a recent study that investigated the connection between dental caries and the prevalence of malocclusion in a limited sample of individuals from a single Albanian city. Their results indicated a substantial correlation between the presence of malocclusions and dental caries [17].

It is crucial to comprehend the occlusal alterations that occur during the transition to permanent dentition, as the development of malocclusion starts with primary teeth. In this sample 52% of the individuals exhibited at least one type of malocclusion.

This prevalence is consistent with the results of prior research, including Tschill et al. [18] and Shen et al. [19], who reported that 37.4% and 45.5% of the Chinese population, respectively, have at least one type of malocclusion.

Nevertheless, other studies demonstrated higher prevalence rates, such as 70%, as demonstrated by Dimberg et al [20], which surpassed the results of our investigation. Malocclusion is more likely to deteriorate as individuals age in this sample. Proffit et al. [21] assert that "the progression of malocclusion is associated with changes in bone structure and dental growth over time." This emphasizes the significance of early intervention in the prevention of long-term complications.

The most prevalent malocclusion in this sample was deep bite (21.40%), with class II malocclusion (19.1%) and increased overjet (19.3%) following closely behind. In their investigation, Shen et al. [19] documented a prevalence of 33.6%. Although the deep bite in the primary dentition may be temporary and may resolve on its own, as a result of vertical mandibular growth and the eruption of permanent molars, class II malocclusion and increased overjet are likely to persist or worsen over time [22].

This is consistent with a longitudinal study conducted by Baccetti et al. [23], which bolsters the concept of deep bite correction. In this sample, the flush terminal plane was observed in 77.2% of cases, which is the optimal molar position in mixed or deciduous dentition. The distal terminal plane was observed in 19% of cases, while the mesial terminal plane was present in 1.5% of the cases.

Malocclusions and oral practices have been the subject of previous research in Tirana, in distinct age groups. Laganà et al. assessed the prevalence of malocclusions and oral habits within a developing Albanian population by conducting a study that involved 2.617 subjects aged 7-15 years [24,25]. Their results suggested that 88.3% of the subjects necessitated orthodontic treatment which is a higher prevalence than that observed in our sample. This implies that the frequency of malocclusions tends to rise as individuals mature.

In addition, the prevalence of deep bite class II and class III malocclusions appears to be quite consistent among different populations. In a study conducted by Esperancinha et al. [26]. the Portuguese population's most prevalent occlusal trait was identified as a deep bite. The study also reported a high prevalence of distal step and increased overjet. In the interim our findings were in accordance with those of another study conducted by Golovachova et al. which also demonstrated a higher prevalence of distal step but a lower prevalence of mesial step [27].

A discernible shift in midline displacement is observed in instances of transversal discrepancies. This displacement may be the consequence of skeletal functional or dental factors. It is intriguing that one-quarter of the patients in this sample also exhibited unilateral posterior crossbite. The most common form of posterior crossbite is unilateral frequently accompanied by a functional mandibular displacement toward the side of the crossbite. This condition is frequently observed in children between the ages of three and twelve and it is typically caused by a narrow maxillary arch [28].

The crossbite side of patients with functional posterior crossbite (FPXB) frequently displays a partial or full Class II molar relationship, whereas the non-crossbite side typically exhibits a Class I relationship because of rotational closure of the mandible [29]. Asymmetric posterior occlusion (2.4%) and unilateral posterior crossbite (2.2%) were observed in our sample, which was indicative of this pattern. It is imperative to identify these issues at an early stage in order to prevent the development of more severe complications in the future. During subsequent craniofacial development a functional unilateral posterior crossbite leads to increased growth on the non-crossbite side while the crossbite side experiences impaired growth [30], potentially resulting in facial asymmetry [31].

There were 543 children aged 3 to 6 years whose parents collaborated by completing questionnaires regarding the presence of oral practices, with 264 females and 279 males participating. Pacifier sucking was the most prevalent tendency, as evidenced by 47.8% of cases. Teeth clenching was observed in 31.8% of cases. and thumb sucking was observed in 8.2% of cases. Oral habits were observed in 85.0% (n. 2.707) of the entire sample examined in Tirana by Laganà [24,25]. The pacifier was the most frequently used oral habit (30%). same as in our study.

The prevalence of anterior open bite was considerably higher among infants with pacifier habits of 48 months or longer, as indicated by Warren et al., and the ideal age to discontinue oral habits is approximately 24 months [32]. The protracted use of the pacifier resulted in substantial modifications to the parameters of the dental arch and occlusal tracts, such as an increase in the width of the mandibular arch and a higher prevalence of the posterior crossbite and the anterior open bite. The duration and frequency of thumb sucking are significant determinants in the development of an asymmetrical anterior open bite [33]. In this investigation, a decreased prevalence of non-nutritive habits, particularly those associated with non-nutritive swallowing behaviors has been observed. The most significant discovery in this sample is the rarity of non-nutritive habits, such as thumb sucking or pacifier swallowing, after 36 months of age. This may account for the absence of statistically significant associations between the presence of these behaviors and occlusal issues. The severity of the deformity is directly proportional to the duration, frequency, and intensity of the habit, which can result in deformities in both the fingers and dental occlusion if these habits persevere with high intensity [34]. Nevertheless, we discovered a statistically significant correlation between the presence of oral breathing and the occurrence of open bites [35]. This finding indicates that a higher index degree is associated with a higher prevalence of deleterious oral habits and mouth breathing, which suggests that these factors are associated with greater malocclusion severity. The second most prevalent oral habit in this sample is teeth clenching, which is observed in 31.8% of the cases. It is a prevalent parafunctional habit in children between the ages of three and six, with a multifactorial etiology that includes occlusal interferences, tension, and airway obstruction. It is frequently regarded as physiological at this stage, as it facilitates neuromuscular development and occlusal adjustment. Nevertheless, dental attrition, muscle tension, or temporomandibular joint issues may result from persistent clenching. The necessity of early identification and monitoring is further underscored by its association with oral respiration and sleep disorders. Assessment of whether it is a temporary habit or necessitates additional intervention necessitates regular dental check-ups and parental awareness.

Conclusion

The results of this cross-sectional study on a preschool Albanian population highlighted the necessity of improving public health programs for orthodontic prevention and screening to organize the resources in this country.

Some results such as deep bite, increased overjet and class II malocclusion prevalence indicate that the necessity of early orthodontic evaluation and targeted public health strategies to mitigate malocclusion development is urgently needed.

Other findings, as the correlation between the presence of an open bite and the tendency of mouth breathing, highlight the importance to start clinical evaluation at three years of age in order to be able to prevent future more severe malocclusions.Preventive measures addressing deleterious oral habits should be integrated into pediatric dental care to support optimal craniofacial development.

Further longitudinal studies are recommended to better understand the progression of malocclusions over time and assess the effectiveness of early interventions.

Declaration

Ethics approval and consent to participate: This study followed the principles laid down by the World Medical Assembly in the Declaration of Helsinki 2008 Helsinki Declarations on medical protocols and ethics and received positive response by the Ethical Committee of the Albanian Catholic University "Our Lady of Good Counsel" (Approval No. 251/2023)

Consent for publication: Written consent was obtained for each subject of the study from parents/guardians.

Availability of data and materials: The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

Competing interests: The authors declare that they have no competing interests.

Funding: No funding was provided.

Authors' contributions: F.V., E.N., S.G. performed the experimental analysis and analyzed the data, A.M. contributed to writing the manuscript, G.L. and P.C. supervised the project and contributed to write and revise the manuscript, I.N. performed the data statistical analysis. All Authors have read and approved the manuscript.

Acknowledgements: Not applicable.

References

1. Peres KG, Barros, AJ, Peres MA, et al. Effects of breastfeeding and sucking habits on malocclusion in a birth cohort study. Rev. Saude Publica 41 (2007): 343-350.
2. Nanda RS, Khan I, Anand R. Age changes in the occlusal pattern of deciduous dentition. J. Dent. Res 52 (1973): 221-224.
3. Laganà G, Lione R, Malara A, et al. Oro-Functional Conditions in a 6-to-14-Year-Old School Children Population in Rome: An Epidemiological Study. Children 12 (2025): 305.
4. Da SFO, Ferrari J, Aiello CA, et al. Correction of posterior crossbite in the primary dentition. J. Clin. Pediatr. Dent 32 (2007): 73-78.
5. Dhar V, Jain A, Van Dyke TE, et al. Prevalenc of gingival diseases, malocclusion and fluorosis in school-going children of rural areas in Udaipur district. J. Indian Soc. Pedod. Prev. Dent 25 (2007): 103-105.
6. Grabowski R, Stahl F, Gaebel M, et al. Relationship between occlusal findings and orofacial myofunctional status in primary and mixed dentition. Part I: Prevalence of malocclusions. J Orofac Orthop 68 (2007): 26-37.
7. Leite-Cavalcanti A, Medeiros-Bezerra PK, Moura C. Breast-feeding, bottle-feeding, sucking habits and malocclusion in Brazilian preschool children. Rev. Salud Pública 9 (2007): 194-204.
8. Carvalho AC, Paiva SM, Scarpelli AC, et al. Prevalence of malocclusion in primary dentition in a population-based sample of Brazilian preschool children. Eur. J. Paediatr. Dent 12 (2011): 107-111.
9. Wagner Y, Heinrichweltzien R. Occlusal characteristics in 3-year-old children- Results of a birth cohort study. BMC Oral Health 15 (2015): 1-6.
10. Borzabadi-Farahani A, Borzabadi-Farahani A, Eslamipuor F. Malocclusion and occlusal traits in an urban Iranian population: an epidemiological study of 11- to 14-year-old children. Eur J Orthod 31 (2009): 477-484.
11. Perillo L, Masucci C, Ferro F, et al. Prevalence of orthodontic treatment need in southern Italian schoolchildren. Eur J Orthod 32 (2010): 46-53.
12. Keski-Nisula K, Lehto R, Lusa V, et al. Occurrence of malocclusion and need of orthodontic treatment in early mixed dentition. Am J Orthod Dentofac Orthop 124 (2003): 631-638.
13. Lopes-Freire GM, Cárdenas AB, Suarez de Deza JE, et al. Exploring the association between feeding habits, non-nutritive sucking habits, and malocclusions in the deciduous dentition. Prog Orthod 16 (2015): 43.
14. Grippaudo C, Paolantonio EG, Luzzi V, et al. Orthodontic screening and treatment timing in preschoolers. Clin Exp Dent Res 5 (2019): 59-66.
15. Paolantonio EG, Ludovici N, Saccomanno S, et al. Association between oral habits, mouth breathing and malocclusion in Italian preschoolers. Eur J Paediatr Dent 20 (2019): 204-208.
16. World Health Organization. Oral health care systems: an International collaborative study. Geneva: WHO (1985).
17. Kongo E, Gribizi I, Spahiu E, et al. Prevalence of malocclusion and oral health-related factors among pre-school children in Northern Albania. J Clin Pediatr Dent 48 (2024): 136-142.
18. Tschill P, Bacon W, Sonko A. Malocclusion in the deciduous dentition of Caucasian children. Eur J Orthod 19 (1997): 361-367.
19. Shen L, He F, Zhang C, et al. Prevalence of malocclusion in primary dentition in mainland China, 1988-2017: a systematic review and meta-analysis. Rep 8 (2018): 4716.
20. Dimberg L, Bondemark L, Soderfeldt B, et al. Prevalence of malocclusion traits and sucking habits among 3-year-old children. Swed Dent J 34 (1): 35-42.
21. Proffit WR, Fields Jr HW, Sarver DM. Contemporary Orthodontics, 5e. Elsevier India (2012).
22. Cabrera-Domínguez ME, Domínguez-Reyes A, Galan-Gonzalez AF. Evolution of the Terminal Plane from Deciduous to Mixed Dentition. Children (Basel) 10 (2023): 1708.
23. Baccetti T, Franchi LM. Longitudinal growth changes in subjects with deepbite. Am J Orthod Dentofacial Orthop 140 (2011): 202-209.
24. Laganà G, Fabi F, Abazi Y, et al. Caries prevalence in a 7 to 15-year-old Albanian schoolchildren population. Ann Stomatol (Roma) 3 (2012): 38-43.
25. Laganà G, Fabi F, Abazi Y, et al. Oral habits in a population of Albanian growing subjects. Eur J Paediatr Dent 14 (2013): 309-313.
26. Esperancinha C, Mendes S, Bernardo M. Malocclusion in deciduous dentition: a cross-sectional study in a Portuguese preschool population. Eur Arch Paediatr Dent 25 (2024): 721-729.
27. Golovachova E, Mikadze T, Kalandadze M. The prevalence of different types of occlusal relationships based on the type of terminal plane in primary dentition: a study among 3- to 6-year-old children in Tbilisi, Georgia. J Dent Res Dent Clin Dent Prospects 16 (2022): 24-28.
28. Preethi K, Rajkumar B, Nagalakshmi S, et al. Correction of morphological and positional asymmetry in early mixed dentition with functional unilateral crossbite. Int J Orthod Rehabil 11 (2020): 82-87.
29. Hesse KL, Artun J, Joondeph DR, et al. Changes in condylar postition and occlusion associated with maxillary expansion for correction of functional unilateral posterior crossbite. Am J Orthod Dentofac Orthop 111 (1997): 410-418.
30. Pinto AS, Buschang PH, Throckmorton GS, et al. Morphologicaland positional asymmetries of young children with functional unilateral posterior crossbite. Am J Orthod Dentofac Orthop 120 (2001): 513-520.
31. Lam PH, Sadowsky C, Omerza F. Mandibular asymmetry and condylar position in children with unilateral posterior crossbite. Am J Orthod Dentofac Orthop 115 (1999): 569-575.
32. Warren, John J, et al. Non-nutritive sucking behaviors in preschool children: A longitudinal study. Pediatric Dentistry 22 (2000): 187-191.
33. Kharat S, Thakkar P, Shetty RS, et al. Oral habits and its relationship to malocclusion: a review. J Adv Med Dent Scie Res 2 (2014): 123-126.
34. Fialho MP, Pinzan-Vercelino CR, Nogueira RP, et al. Relationship between facial morphology, anterior open bite and non-nutritive sucking habits during the primary dentition stage. Dental Press Journal of Orthodontics 19 (2014): 108-113
35. Grippaudo C, Paolantonio EG, Antonini G, et al. Association between oral habits, mouth breathing and malocclusion. Acta Otorhinolaryngol Italy 36 (2016): 386-394.