Malocclusion prevalence in an ethnic Chinese
population
K. K. Lew, BDS, MDS, AM*
W. C. Foong, BDSt
E. Loh, BDSS
Key words: Chinese, malocclusion, prevalence.
Abstract
Population norms derived from one ethnic group
may not necessarily be valid and accurate for other
ethnic groups. With the increasing number of ethnic
Chinese immigrants in Australia, Europe, and
America, it would be useful for dental practitioners
to be informed about malocclusion prevalence
among Chinese. This study was carried out on 1050
Chinese school children (aged 12-14 years) to
assess both qualitatively and quantitatively certain
occlusal features. The populationwas found to have
a high incidence of Class Ill malocclusions com-
pared with Caucasians. However, the incidence of
Class II malocclusions was quite similar to those
reported in Caucasians. Normal occlusions occurred
in about 7 per cent of this population. Although this
percentage was much lower than those reported in
blacks, it was similar to those reported in caucas-
ians. Crowding occurred in about 50 per cent of
cases, which was slightly less than for those re-
ported for Caucasians. Increased overbites were also
less common in this Chinese population compared
with Caucasians. Compared with Caucasians, cross-
bites were also less frequent in this Chinese
population.
(Received for publication February 1992. Revised
July 1992. Accepted July 1992.)
*Senior Lecturer in Orthodontics, Department of Preventive
Dentistry, National University of Singapore.
tFormer Dental Officer, National University Hospital,
Singapore.
$Former Dental Officer, Government Dental Clinic, Singapore.
442
Introduction
Although the Chinese ethnic group comprises
close to a quarter of the world's population, no
malocclusion study on a large sample of Chinese
school children in the early permanent dentition
stage has been published. Johnson',' in his evalua-
tion of 210 school children has provided some data
on the malocclusion status in Chinese. However,
because his sample was comprised of children with
ages ranging from 7 to 13 years, with possibly only
36 subjects in the permanent dentition stage (that
is 2 12 years), the assessment of some malocclu-
sion parameters may not be representative of the
true malocclusion status in the Chinese racial
group.
One of the biggest problems in assessing mal-
occlusion is the choice of an index which is both
reliable and repeatable. In an attempt to distinguish
patients in need of orthodontic care, several systems
of classifying malocclusions have been propo~ed.~-''
The determination of objective signs of malocclusion
have been studied by either clinical examination of
patients and/or from plaster casts of the patients'
dental arches. Orthodontic treatment indices
attempt to quantify dentofacial attractiveness and
serve as epidemiological tools for assessment of
malocclusion prevalence or changes in its disease
pattern. Morphological characteristics of malocclu-
sion when evaluated in the light of psychosocial
information may allow epidemiologists to project
national treatment needs.' However, because of the
varying impact of similar malocclusions under
dissimilar cultural and social milieux, it is not
surprising that no present index is universally
accepted as a means of assessing treatment needs.I2
Australian Dental Journal 1993;38(6):442-9.
Table 1. Distribution of sample
Age (years) Males Females Total
12 100 99 199
13 260 310 570
14 160 121 28 1
Total 520 530 1050
Current epidemiologic data are necessary to detect
trends and changes in the prevalence of malocclu-
sions.” While some areas of dentistry such as caries
prevalence are declining in importance from a treat-
ment perspective, orthodontic care will continue to
increase in importance as more children and adults
seek treatment, especially in the more amuent
societies. The purpose of this study is to provide
local data on the prevalence of malocclusion in a
group of Chinese children at an age when ortho-
dontic treatment is usually carried out in Singapore.
The morphological and morphometric charac-
teristics of malocclusion will also be investigated.
The results from this study may be used by both
clinicians and epidemiologists to project preventive
and interceptive orthodontic needs in the Chinese
racial group which comprises 77.7 per cent of
Singapore’s population of more than 3 million
people.12
Materials and methods
The sample consisted of 1050 Chinese school chil-
dren (520 boys, 530 girls) aged 12-14 years (mean
age 13.1 f0.9 years) (Table 1). The subjects chosen
exhibited the presence of permanent teeth from first
molar to its antimere in both arches, had no history
of orthodontic treatment, no history of early loss
of deciduous teeth, no extractions of permanent
teeth, no history of skulllfacial operations or skull
fractures or systemic conditions which could affect
craniofacial growth and occlusal development.
Each subject, seated on a dental chair, was
initially examined intra-orally with a dental mirror,
periodontal probe and millimetre rule. The assess-
ments were carried out in a centralized dental clinic
over a period of five weeks. With the exception of
the assessment of crowding and spacing where the
mouths were wide open, the other parameters such
as overjet-overbite and the presence of crossbite
were assessed when the subjects were in maximum
intercuspation. A score card with the subject’s
particulars and examination results was completed
for each subject. The following malocclusion
parameters (which were quite similar to Foster and
Day’s study”) were measured and recorded by one
investigator.
Australian Dental Journal 1993;38:6.
1. Dental arch relationship
The anterior-posterior arch relationships were
assessed according to Angle’s criteria. They were
classified into Class I normal occlusion, Class I
malocclusion, Class I1 division 1, Class I1 division
2 and Class I11 malocclusions.
2. Dental arch crowding/spacing
This was assessed from first molar to its antimere
in both arches. Crowding was classified as present
when there was overlapping of teeth while spacing
was classified as present when diastemas were
evident between the teeth. If crowding and spacing
was present in the same arch, then the crowding
and spacing was measured to the nearest 0.5 mm
and the nett amount of crowdinglspacing was deter-
mined. The crowdinglspacing was recorded
separately for each arch.
3. Incisal overjet
This was the measure of the horizontal overlap
of the four incisors. Overjets were measured to the
nearest 0.5 mm. The mean overjet of all 4 incisors
was determined and categorized as follows.
(a) Normal: Mean positive overjet up to 3 mm.
(b) Increased: The mean positive overjet was
greater than 3 mm.
(c) Edge to edge: The mean overjet was edge-to-
edge in occlusion.
(d) Reversed: The mean overjet was negative.
4. Incisal overbite
This was the mean vertical overlap of the four
incisors. The overbite of each incisor was measured
to the nearest 0.5 mm. Overbites were classified as
follows.
(a) Normal: The mean upper incisal overlap was
between 15-40 per cent of the clinical crown length
of the lower incisors.
(b) Increased: The mean upper incisal overlap
exceeded 40 per cent of the clinical crown length
of the lower incisors.
(c) Decreased The upper incisors overlapped less
than 15 per cent of the clinical crown lengths of
the lower incisors.
5. Crossbite
This was the transverse relationships of the upper
first molars to those of the lower first molars in
maximum intercuspation. A buccal crossbite was
deemed to exist when the buccal cusps of the upper
molars were lingual to the buccal cusp of the lower
molars, and a scissor bite when the palatal cusps
443
 perfectCL1 CLI CL I1 Div 1 CL I1 Div 2 CL 111
Fig. 1. -Percentage distribution of dental arch relationship.

Crowding Spacing
0 Maxilla
Mandible
Fig. 2. -Percentage distribution of dental arch crowdinglspacing.

of the upper molars were buccal to the buccal cusp
of the lower molars. Buccal crossbites and scissor
bites were classified as unilateral or bilateral.
Results
The results of the study are shown in Figs. 1-5.
1. Dental arch relationship (Fig. 1)
Normal occlusion accounted for 7.1 per cent
(n = 75) of the sample, whilst Class I malocclusions
had the highest incidence at 58.8 per cent (n = 616).
Class I1 division 1 and Class I1 division 2 mal-
occlusions were recorded at 18.8 per cent (n = 197)

444 Australian Dental Journal 1993;38:6.

 Ideal OJ IncreasedOJ Edge-@Edge, NegativeOJ
Fig. 3.-Percentage distribution of incisal overjet.

Ideal OB Increased OB Decread OB

Fig. 4. -Percentage distribution of incisal overbite.

and 2.7 per cent (n=28), respectively. The inci-
dence of Class I11 malocclusions was 12.6 per cent
(n = 134).
2. Dental arch crowdinghpacing (Fig. 2)
Maxillary arch crowding was observed in slightly
less than half of the sample at 49.7 per cent
(n = 522), whereas crowding in the mandibular arch
was observed in 52.7 per cent (n=533) of the
sample. Spacing was more prevalent in the maxillary
arch at 5.2 per cent (n = 55) as compared with the
7.2 per cent (n = 76) found in the lower dentition.
3. Incisal overjet (Fig. 3)
Ideal overjet was noted in 68.2 per cent (n = 716)
of the sample, while increased overjet was found
in 19.2 per cent (n=202) of the sample. The in-
cidence of edge-to-edge incisal relationship was 2.7
per cent (n=28) while negative overjet was
recorded at 9.9 per cent (n = 104).
4. Incisal overbite (Fig. 4)
Ideal overbite accounted for 46.5 per cent
(n=488) of the sample. While 28.4 per cent
(n = 298) of the sample had an increased overbite,

Australian Dental Journal 1993;38:6. 445

 None Unilateral
buccal
Fig. 5. -Percentage distribution of crossbite relationship.
25.1 per cent (n = 264) of the sample had decreased
overbite.
5. Posterior crossbite (Fig. 5)
The majority of the sample (91.9 per cent,
n = 965) did not have any form of posterior cross-
bite. Unilateral buccal crossbite was found in 6.1
per cent (n = 64) while 1.3 per cent (n = 14) of the
sample had bilateral buccal. Unilateral and bilateral
scissor bites were relatively rare and accounted for
only 0.5 per cent (n = 5) and 0.2 per cent (n = 2)
of the sample, respectively.
Discussion
Numerous problems are encountered when
comparing studies on malocclusion tatu us,^^^^^^^
particularly regarding the varying systems used by
different investigators to classify and quantify
occlusal status. Most studies in their attempt to
determine the prevalence of malocclusion have
divided malocclusion into five components: (1)
crowding; (2) anteroposterior incisor relation
(overjetheverse overjet); (3) anteroposterior molar
relationship; (4) vertical incisor relationship; and
(5) crossbite relationship. The morphologic compon-
ents of malocclusion in childrcn,1s-18a d o l e s ~ e n t s ' ~ * ~ ~examiner^.^,'^
and adult^^^-^^ have been reported. These studies
demonstrate that the morphologic and morphometric
components of malocclusion vary with age and
racial type. Heikinheimo, Salnis and Myllarniemi~,'~ I11 malocclusions to be 62 per cent, 16 per cent and
in a longitudinal study of Swedish children from
7 to 10 years old, found that severe maxillary over-
jets increased from 17 per cent to 27.2 per cent with
age, while maxillary and mandibular incisor crowd-
ing decreased from 26.7 per cent to 18.2 per cent,
446
Bilateral Unilateral Bilateral
buccal scissor scissor
and 34.1 per cent to 10.2 per cent respectively.
Minimal changes were reported in deepbite, Class
I1 relationships and cros~bite'~ during the period
from 7 to 10 years of age. About 70-75 per cent of
adolescents were judged to have malocclusion of
some degree."
The prevalence of Angle's malocclusion types
among different ethnic groups such as
A m e r i c a n ~ , ~ ~BritishY2*
-~' IndiansY3l
P ~ l y n e s i a n shas
~ ~ been described. On
limited sample sizes, malocclusion incidence in
and Malays34has also been reported.
The C h i n e ~ e , ' , ~Malays,34
.~~ Black
Egyptians3' and appear to have a higher
incidence of Class I11 malocclusions compared with
the Caucasian races (Table 2). In general, the in-
cidence of malocclusion in descending order of
prevalence is Class I malocclusion, Class I1 mal-
occlusion, Class 111 malocclusion. The exception
to this trend is noted in Malays34and,
to a lesser extent, and Swedes.37
Although some of these differences in incidences
reflect ethnic trends, a host of other factors also
contribute to these variations. Some of these include
differences in age,33sexa3and definition of evalua-
tion criteria and the lack of standardization amongst
The study by Johnson, Seetemat, and Winoto2
on 210 Singapore Chinese children aged 7-13 years
showed the incidence of Class I, Class I1 and Class
22 per cent, respectively. Woon, Thong, and
Kadir,34 studying 154 Malaysian Chinese subjects
with a mean age of 16.5 years, found Class I molar
relationships in 52 per cent, 15 per cent having
Class I1 molar relationships and 33 per cent having
Australian Dental Journal 1993;38:6.
Table 2. Malocclusion in the permanent dentition among different ethnic groups
Per cent prevalence
Ethnic group Sample size
Normal occlusion Class I Class I1 Class I11
American caucasiansa5 718 6.8 65.2 22.5 5.5
American BIackP 445 31.3 44.0 16.0 8.7
Briti~h’~ 1000 52.0* 52.0 4.0
Chinese3’? 154 52.0 15.0 33.0
Erntiads 501 34.3 33.3 21.0 10.6
Eskimo36 100 18.0 64.0 8.0 10.0
Indian”? 42 67.0* 22.0 11.0
KiKuyu Kenyan” 505 16.8 51.7 7.9 16.8
Malay”? 151 57.0* 14.0 29.0
SwedishQ 301 10.0 83.0 3.0 4.0
Lew (present study) 1050 7.1 58.8 21.5 12.6
*Includes normal occlusion.
?Based on molar relationship.

Class I11 molar relationships. In the present study, sampling techniques and diagnostic criteria. The
the incidence of Class I11 malocclusions was 12.6 incidence of Class I malocclusions and Class I1
per cent. Although the percentage of Class I11 malocclusions appeared quite similar to those
malocclusions was high compared with Caucasians, reported by other on Chinese samples.
this value was lower than those reported by Johnson Slightly over 7 per cent of the subjects in the
et al.’ and Woon et al.34on Chinese populations. present sample had perfect Class I occlusions
Such differences could arise because of variation in (normal occlusion). This compares favourably with
those reported on American Caucasians (6.8 per
cent),” but is much less than those reported in
Table 3. Percentage distribution of American Blacks (31.3 per cent)32 and Black
occlusal features between Caucasians and Africans in a rural isolated community (82 per
Chinese ~ e n t ) . ~This
’ increased incidence or normal occlu-
Caucasians” Chinese (present sions can partly be explained by GardineP who
Occlusal condition (n = 1000, study) (n = 1050, found that in genetically pure races, malocclusion
aged 12 years) aged 12-14 years) is almost non-existent.
1. Dental arch relationship In this study the assessment criteria were inten-
Normal 44.3 7.1 tionally modelled after those of Foster and Days3
Class I 58.8 so that a comparative study of malocclusion in-
Class I1 division 1 34.5* 18.8
Class I1 division 2 17.7 2.7
cidence between Chinese and Caucasian could be
Class I11 3.5 12.6 drawn (Table 3). The present study showed that
2. Dental arch crowding crowding was seen in about 50 per cent of subjects,
Maxillary 61.1 49.7 with minimal differences in the incidence of
Mandibular 57.5 52.7 crowding between arches. Foster and Day,13 in their
3. Incisal overjet study of 1000 British 11-12 year olds, reported
Normal 48.9 68.2 crowding in 60 per cent of their sample. Crowding
Increased 47.7 19.2
Edge-to-edge 1.7 5.8 in the Chinese population appeared to be lower.
Reverse 1.7 6.8 This finding corroborates with those of Ga~diner’~
4. Incisal overbite who studied the relation between cephalic index and
Normal 29.1 46.5 crowding. G a ~ d i n e rfound
~ ~ that the larger the
Increased 55.9 28.4 cephalic index (that is, brachycephalics) the lesser
Decreased 15.0t 25.1
the degree of crowding. en lo^,^^ in his study on
5. Posterior crossbite
None 87.2 92.9
craniofacial skeletons, has revealed a greater propor-
Buccal (unilateral) 8.7 6.1 tion of brachycephalics in Mongoloids (which
Buccal bilateral) 4.1 1.3 includes the Chinese racial type) compared with
Scissor (unilateral) - 0.5 Caucasians. Findings of crowding compare favour-
Scissor (bilateral) - 0.2 ably with those of Woon et on Malaysian
*Includes Class I1 indefinite. Chinese but were less than the 61 per cent of
?Refers to incomplete overbite and anterior or open bite. crowded arches observed by Foster and Days3 in

Australian Dental Journal 1993;38:6. 447

 12 year old Caucasians. The incidence of spacing
in the present study was 6 per cent and 7 per cent
in the maxillary and mandibular arches, respec-
tively, These findings were similar to those reported
by Woon et al.34on Chinese.
Consistent with the findings on dental arch rela-
tionships, the present sample exhibited a greater
percentage of edge-to-edge relationships and revers-
ed overjets compared with Foster and Day.13 In
their study, the authors reported incidence of edge-
to-edge relationships and reversed overjets to be less
than 4 per cent. While the majority of caucasiansL3
had increased overbites, the majority of Chinese
appeared to have normal overbite relationships.
This could be related to the higher percentage of
Class I1 malocclusions in Caucasians compared with
this Chinese sample, as pointed out by Foster and
Day.13
Buccal crossbites were seen in almost 13 per cent
of c a ~ c a s i a nbut
' ~ only in 7.5 per cent of Chinese.
The lower incidence of buccal crossbites in Chinese
could be related to the tendency for the Chinese
racial type to be brachyfacial and therefore possess
comparatively larger maxillary Consistent
with the finding of Foster and Day on ca~casians,'~
scissor bite (lingual crossbite) was rare in this
present Chinese sample.
The present investigation highlights the need for
undertaking similar malocclusion surveys on
subjects of mixed Asian-Caucasian heritage, since
there appears to be an increasing trend of such
individuals in many countries with large immigrant
populations.
Conclusion
Specific differences between Caucasian and
Chinese malocclusions are evident. With Chinese
immigrant populations increasing in Australia,
America, and Europe, treatment of patients of
Chinese origin will increase. Because of this trend,
knowledge of the morphometric differences in
occlusal parameters among different ethnic groups
will be usehl both from the epidemiological stand-
point of dental health treatment needs as well as
for the clinician carrying out orthodontic treatment.
Acknowledgement
The typographical assistance of Mrs C. Tham is
gratefully acknowledged.
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Address for correspondencehprints:
Faculty of Dentistry,
National University of Singapore,
National University Hospital,
Lower Kent Ridge Road,
Singapore 05 11.
449