The relationship of anterior overjet to plaque and

gingivitis in children
T. M. Davies, B.D.S., D. Orth., M.Sc., F.D.S.R.C.S.,
W. C. Shaw, B.D.S., Ph.D., Y.Sc.D., F.D.S.R.C.S., D. Orth., D.D.O.,**
M. Addy, B.D.S., Ph.D., M.Sc., F.D.S.R.C.S.,*** arid P. M. H. Dummer, B.D.S., M.Sc.D.****
Manchester, England, and Card$ Wales, United Kingdom

The aim of the present investigation was to evaluate the relationship of overjet to periodontal
status. Detailed examinations of occlusal and periodontal characteristics were completed on 914
12-year-old children. Plaque indices, bleeding indices, and anterior overjet were recorded for each
incisor tooth. There was a significant association between mean plaque scores and the extremes of
overjet measurement, suggesting that tooth cleaning is more difficult in these cases. Also, it was
apparent that for right-handed children, the plaque and gingivitis scores were lower on the left side
of the mouth. (AM J ORTHOO DENTOFAC ORTHOP 1988;93:303-9.)

T ogether with cosmetic change, dental

health implications of malocclusion represent a signif-
icant motive for orthodontic treatment, both for the
providers and the consumers of orthodontic care. How-
ever, such topics have attracted remarkably little in-
depth research despite their fundamental importance.
In the present climate of critical health economics and
the possible application of priority indices for third-
party payment agencies, clinicians in many countries
have a need for more robust data.
These circumstances provided the background for
a longitudinal multidisciplinary study of associations
between malocclusion and a range of social-psychologic
and dental health issues. The strategy for investigation’
describes the sampling technique and the indices of
caries, periodontal status, mandibular function, occlu-
sal status, and social-psychologic features. Compre-
hensive data for a cohort of 1,015 subjects 11.5 to 12.5
years old, weighted to include occlusal features of low
prevalence but high orthodontic interest, were obtained
in 198 1. Eight hundred of the subjects were reexamined
in 1984, and further assessments into adulthood are
projected. For the present report, relevant data for
studying associations between periodontal status and
overjet were abstracted.
Findings from epidemiologic studies have consis-
tently demonstrated a close relationship among the age
of a population, the oral hygiene condition, and the
frequency and severity of periodontal disease.* There
are reasons to assume that most, if not all, plaque-
associated periodontal disorders start as an overt in-
flammation in the gingivae.3,4 In most patients the se-
verity of various clinical signs of periodontal disease
varies not only from tooth to tooth, but also from one
tooth surface to another.5.6
Persons with the necessary skills and motivation can
remove supragingival plaque’ and prevent the onset of
gingivitis. Arguably, this may be facilitated by having
well-aligned dental arches.* However, associations be-
tween dental irregularities and periodontal disease have
been uncertain.g For example, the relationship of an-
terior over-jet to the periodontal disease process is of a
contradictory nature. Some authors report that it is an
important etiologic factor, ‘O-‘*while other observers re-
port little or no influence on periodontal health.‘g-24
The aim of this investigation was to examine as-
sociations between variations in anterior overjet with
maxillary and mandibular incisor plaque accumulation
and gingivitis in subjects aged 11.5 to 12.5 years. As
such, the present article is the first of a series of reports
concerning malocclusion and dental health in this
cohort.

Supported by DHSS Grant JR 128128 BLG. METHOD

*Senior Registrar in Orthodontics, University Dental Hospital of Manchester.
**Professor of Orthodontics, University Dental Hospital of Manchester.
***Reader in Periodontology, Welsh National School of Medicine.
****Lecturer in Conservative Dentistry, Welsh National School of Medicine.
Data for left-handed children were eliminated from
the present analysis since the distribution of plaque and
gingivitis differs from that of right-handed persons.’
303
304 Davies et al.

Tat& 1. Distribution of overjet in the sample

-----.
2l ri k iz
Maxillary right Maxillary right Maxillary teft Maxillary leji
Subgroup lateral incisor central incisor central incisor iateral incisor

Normal overjet 586 565 559 612

0.5 mm to 4 mm (68.1%) (62.8%) (62%) (71.5%)
Reverse overjet 111 34 31 76
-5mmtoOmm (12.9%) (3.8%) (3.4%) (8.9%)
Moderate overjet 158 234 242 lb3
4.5 mm to 8 mm (18.4%) (26%) (26.8%) (19%) .~
Severe overjet 5 66 70 5
8.5 mm to 15 mm (0.6%) (7.3%) (7.8%) (0.6%)
TOTAL 860 899 902 856
(100%) (100%) (100%) (100%)

TatHe II. Buccal plaque index for overjet subgroups (mean and standard errors)*

2J Ll k jJ
Maxillary right Maxillary right Maxillary left Maxillary left
Subgroup lateral incisor central incisor central incisor lateral incisor

Normal overjet abc de

0.5 mm to 4 mm 1.76 (0.032) 1.30 (0.034) 1.05 (0.036) 1.48 (0.035)
Reverse overjet a d
-5mmtoOmm 1.84 (0.076) 1.74 (0.129) 1.48 (0.160) 1.55 (0.105)
Moderate overjet b
4.5 mm to 8 mm 1.89 (0.061) 1.46 (0.053) 1.19 $055) 1.50 (0.069)
Severe overjet C
8.5 mm to 15 mm 1.80 (0.490) 1.64 (0.098) 1.27 (0.095) 1.60 (0.510)

J -ii r;; ti
Mandibular right Mandibular right ~Mandibular left Mandibular left
Subgroup lateral incisor central incisor central incisor lateral incisor

Normal overjet f tich

0.5 mm to 4 mm 1.74 (0.035) I.37 (0.037) 1.29 (0.037) 1.40 (0.034)
Reverse overjet g
-5mmtoOmm 1.90(0.080) 1.76 (0.163) 1.52 (0.160) 1.61 (0.106)
Moderate overjet h
4.5 mm to 8 mm 1.87 (0.066) 1.53 (0.059) 1.38 (0.058) 1.45 (0.065)
Severe overjer f
8.5 mm to 15 mm 2.60 (0.245) 1.59 (0.101) 1.46 (0.101) 1.80 (0.200)

*Paired letters (a/a, h/b, etc.) denote statistically signitkant differences between thehe-groupsat P -C 0.05 level.

This left a study population of 914. Measurement ~of
overjet for each maxillary incisor was made to the near-
est 0.5 mm with a millimeter rule on registered study
casts. Original registration of the casts was performed
with the aid of a wax bite-and a tape-recorded descrip-
tion of occlusal relationships in intercuspal position.’
For the purpose of analysis, individual maxillary inci-
sors were grouped by overjet into’ the following
subgroups: reverse overjet, - 5 mm to 0 mm; normal
overjet, 0.5 mm to 4 mm; m&e&e overjet, 4.5 mm
to 8 mm; and severe overjet, 8.5 mm to 15 mm (Ta-
ble I).
Plaque accumulation on the buccal and lingual sur-
faces of the incisors was recorded by means of the index
of Silness and L&zzf Bleeding of thegingivae ang&tle
probing is considered to be the earhest &nical signof
Volume 93 Relationship of anterior overjet to plaque and gingivitis 305
Number 4

Table III. Lingual plaque index for overjet subgroups (mean and standard errors)*

ZJ 1J IL 12.
Maxillary right Maxillary right Maxillaty left Maxillary left
Subgroup lateral incisor central incisor central incisor lateral incisor

Normal overjet ab de fg
0.5 mm to 4 mm 0.46 (0.022) 0.42 (0.022) 0.52 (0.023) 0.59 (0.023)
Reverse overjet d li
-5mmtoOmm 0.74 ;:.052) 0.65 (0.093) 0.71 (0.106) 0.91 (0.065)
Moderate overjet bc gb
4.5 mm to 8 mm 0.56 (0.044) 0.47 (0.034) 0.57 (0.037) 0.76 (0.045)
Severe overjet hi
8.5 mm to 15 mm 0.40 (0.400) 0.57 (eo.069) 0.64 (0.071) 0.20 (0.200)

z1 TI k i-5
Mandibular right Mandibular right Mandibular left Mandibular left
Subgroup lateral incisor central incisor central incisor lateral incisor

Normal overjet
0.5 mm to 4 mm 0.93 (0.026) 1.03 (0.030) 1.06 (0.030) 0.95 (0.026)
Reverse overjet
-5mmtoOmm 0.95 (0.061) 0.97 (0.119) 0.87 (0.111) 0.84 (0.070)
Moderate overjet
4.5 mm to 8 mm 0.99 (0.050) 1.04 (0.045) 1.07 (0.046) 1.03 (0.049)
Severe overjet
8.5 mm to 15 mm 1.20 (0.200) 1.09 (0.083) 1.12 (0.072) 0.80 (0.200)

*Paired letters (a/a, b/b, etc.) denote statistically significant differences between the groups at P < 0.05 level.

chronic gingivitis,26 and the presence or absence of Congenital absence of maxillary lateral incisors and loss
bleeding from the buccal, mesial, and lingual gingivae of maxillary central incisors due to trauma are the prob-
was noted after gentle probing of the gingival margin able causes for the discrepancy in the total number of
for plaque. The scoring used a simple positive or neg- incisors in each group.
ative scheme: 0 = no bleeding, 1 = bleeding.
Mean plaque scores were computed for the maxil- PLAQUE
lary and corresponding mandibular incisors for each The mean buccal plaque scores for mandibular and
overjet subgroup. The significance of differences be- maxillary incisors in each overjet group are given in
tween the subgroups was estimated by analysis of var- Table II. For the purpose of clarity in the tables and to
iance and a multiple comparison procedure (Duncan’s identify the members of the pair showing significant
multiple range). The proportion of positive bleeding differences, we have chosen letter notations (a/a, b/
sites was calculated for each subgroup per tooth and b, etc.). For example, in Table II, there is a significant
the significance of differences between groups was cal- difference between the normal and reverse overjet
culated by the chi-square test. subgroups for the maxillary right central incisor as de-
noted by matching the letters a/a. For each tooth type,
RESULTS the mean buccal plaque index was increased in the
A summary of the distribution of overjet for max- abnormal overjet groups when compared with the nor-
illary incisors in this population group is shown in Ta- mal overjet group. These differences were apparent for
ble I. The largest group was made up of children with both maxillary and mandibular incisors. These differ-
normal overjet (>60%). The reverse overjet group con- ences were significant for some teeth-notably, max-
tained a larger number of lateral incisors (n = 187) illary central incisors and mandibular right central and
than central incisors (n = 65), whereas moderate and lateral incisors. A further feature of note was the in-
severe overjet groups included a greater number of cen- creased mean buccal plaque on right contralateral max-
tral incisors (n = 612) than lateral incisors (n = 33 1). illary and mandibular incisor teeth in all overjet groups.
306 Davies et al.

Tabie IV. Buccal bleeding index and overjet measurements*

-_-”
Percentage of teeth showing a positive bleeding score
-- _-.
2l 4 Ir k
Maxillary right Maxillarv right Maxillary left Maxillary lefi
Subgroup lateral inckor central i;tcisor central incisor lateral in+r

Normal overjet abc

0.5 mm to 4 mm 73.55% 64.60% 52.87% 61.60%
Reverse overjet a
-5mmtoOmm 74.77% 82.35% 54.84% ?I .05%
Moderate overjet b
4.5 mm to 8 mm 79.75% 72.77% 55.37% 65.03%
Severe overjet c
8.5 mm to 15 mm 60.00% 80.30% 67.14% 60.00%

?I 71 ii IT
Mandibular right Mandibular right Mandibular left Mandibular left
Subgroup lateral incisor central incisor central incisor lateral incisor

Normal overjet
0.5 mm to 4 mm 65.99% 54.01% 46.42% 48.78%
Reverse overjet
-5 mmtoOmm 78.5?% 63.64% 45.16% 56.58%
Moderate overjet
4.5 mm to 8 mm 69.62% 62.23% 49.79% 51.53%
Severe overjet
8.5 mm to 15 mm 80.00% 57.58% 51.43% 60.00%

*Paired letters (a/a, b/b, etc.) denote statistically significant differences between the groups at P < 0.05 level.

The mean lingual plaque scores for mandibular and
maxillary incisors in each overjet group are shown in
Table III. For maxillary incisors there was again a trend
for increased plaque scores in the reverse, moderate,
and severe overjet groups compared with the normal
over-jet group. Several differences were found to be
signiticant. The exception- to the overall trend was the
reduced lingual plaque on maxillary lateral incisors in
the severe overjet group.
Mandibular incisors overall showed small differ-
ences in lingual plaque scores in the overjet groups and
no significant differences were found. Left- and right:
sided differences were not apparent for lingual plaque.
BLEEBWG
The prevalence of bleeding at buccal, mesial, and
lingual sites for maxillary and mandibular incisors is
shown in Tables IV through VI.
For maxillary incisors the prevalence &bleeding at
the buccal, mesial, and lingual sites -was increased in
the reverse, moderate, and severe overjet grou.ps com-
pared with the normal over-jet group. Some of these
differences reached signifkance as did the differences
between the reverse, moderate, and severe overjet-
groups. The prevalence of mandibular bleeding showed
no particular pattern throughout the overjet groups .and
few differe&ces were found to besignifkant.
For buccal and mesial bleeding, a shift to increased
bleeding on the right side was apparent for contraiateral
tooth pairs. This feature was not seen for lingual
bleeding.
The data set abstracted for the present report is part
of an archive of longitudinal data on the occlusal-status,
dental health, and social-psychologic development of a
cohort of 1015 subjects who were 11.5 to 12.5 years-
old at initialexarnination. ’ We intend to use this archive
to determine synchronic multivariate associations
among the different sections of the archive, but it is
anti&p&d that the study’s gmatestyield will be in the
exarnmations of changes occurring through time and,
in particular, the effectiveness (or otherwise) of ortho-
dontic treatment.
Volume 93 Relationship of anterior overjet to plaque and gingivitis 307
Number 4

Table V. Mesial bleeding index and overjet measurements*

Percentage of teeth showing a positive bleeding score

4 rl IL I?
Maxillary right Maxillary right Maxillary left Maxillary lef
Subgroup lateral incisor central incisor central incisor lateral incisor

Normal overjet ab de f
0.5 mm to 4 mm 71.50% 46.90% 33.93% 62.91%
Reverse overjet d
-5mmtoOmm 69.37% 67.:5% 54.84% 71.05%
Moderate overjet bc e
4.5 mm to 8 mm 79.11% 51.49% 42.98% 62.58%
Severe overjet C f
8.5 mm to 15 mm 60.00% 69.70% 54.29% 80.00%

ZI TI F Iz
Mandibular right Mandibular right Mandibular left Mandibular left
Subgroup lateral incisor central incisor central incisor lateral incisor

Normal overjet @
0.5 mm to 4 mm 51.02% 47.06% 44.27% 44.55%
Reverse overjet g
-5mmtoOmm 63.39% 57.58% 51.61% 42.11%
Moderate overjet b
4.5 mm to 8 mm 63.92% 46.35% 43.98% 49.69%
Severe overjet
8.5 mm to 15 mm 40.00% 51.52% 52.86% 80.00%

*Paired letters (a/a, b/b, etc.) denote statistically significant differences between the groups at P < 0.05 level.

This report is one of a series of analyses of the
occlusal and periodontal statuses of the cohort at base-
line and focuses very specifically on overjet. It is rec-
ognized that orthodontic treatment of overjet variations
is undertaken for a variety of reasons-for example,
reduced vulnerability to trauma,27.28possible avoidance
of tooth migration and instability in adulthood, and,
not least, cosmetic improvement. 29
Loss of attachment was not considered to be a rel-
evant measure for the cohort at 12 or 15 years of age
although its recording in the adult is likely to be nec-
essary. Pocketing was measured, but its inclusion in
the present analysis did not provide significant addi-
tional information and has been omitted.
The findings indicate that maxillary and mandibular
teeth in extreme positive and negative overjet relation-
ships are more liable to plaque accumulation and gin-
givitis. This is true for the buccal and lingual aspects
of maxillary incisors, but only for the buccal aspect of
mandibular incisors.
The strength of the association for individual teeth
was not, however, always clear-cut or consistent. The
magnitude of the differences detected among overjet
subgroups was not of major clinical relevance within
the context of general factors associated with plaque
accumulation. For example, plaque accumulation and
bleeding frequency varied as much between right- and
left-sided teeth (buccal aspects) within the same overjet
ranges as among the overjet subdivisions. Similarly,
equally large differences were demonstrated between
the sexes and, for girls, between high and low social
class backgrounds,30 these latter differences being re-
lated to reported tooth brushing frequency.3’-34 It is not
entirely clear why this should be the case as toothbrush
access would not seem to be impaired by this trait (in
contrast to local interdental irregularities). The expla-
nation may be in modification of natural cleansing
mechanisms, such as tongue position and behavior (es-
pecially for lingual surfaces),35v36and lip position and
behavior on the labial aspect, including protection from
dehydration. It is also conceivable that persons with
unattractive teeth are less inclined to brush them reg-
ularly and well. (This issue will be reported separately.)
The magnitude of the effects noted herein must,
however, be kept in perspective. The large sample stud-
ied and its weighting for severe malocclusion have pro-
Table VI. Lingual bleeding index and overjet measurements*
----.--.
Percentage of teeth showing a positive bleeding score
-,--- -..
a 4 k
Maxillary right Muxillu~ righr Mariltky ieft Maxi&q lefi
Subgroup lateral incisor central incisor central incisor lateral in&Or
1
Normal overjet a cde f gh
0.5mmto4mm 20.65% 16.11% 21.54% 30.93%
Reverse overjet ab C fci
-5mmtoOmm 45 .OS% 35.29% 32.26% 60.53%
Moderate overjet b d hi
4.5 mm to 8 mm 22.15% 22.13% 27.27% 42.94%
Severe overjet e f
8.5 mm to 15 mm 20.00% 3 I .82% 35.71% 20.00%

a 51 b k
Mandibular right Mandibular right Mandibular left Mandibular lejt
Subgroup lateral k&or central incisor central incisor lateral incisor

Normal overjet
0.5 mm to 4 mm 28.40% 38.26% 40.75% 37.89%
Reverse overjet
-5mmtoOmm 33.93% 39.39% 35.48% 36.84%
Moderate overjet
4.5 mm to 8 mm 26.58% 38.63% 42.74% 41 .lOW
Severe overjet
8.5 mm to 15 mm 20.00% 39.39% 35.71% 20.00%

*Paired letters (a/a, b/b, etc.) denote statistically significant differences between the groups at P i 0.05 level.

vided an optimal setting for disclosing the adverse ef- 8

fects of overjet variation. The explanatory effect of
individual tooth irregularity, contact-point discrepancy,
has also been calculated for the ~tiple.~~ However,
other data underline the sahence of background vari-
ables. Thus, the magnitude of disadvantage conferred
by overjet extremes may well be outweighed by vari-
ations between sexes and social classes, and by the
effect of~toothbrushing. ‘OJ‘s30In other words, the ca-
pacity for improvement in gingival health to be gained
by orthodontic correction per se may be surpassed by
the modification of personal oral hygiene skill and at-
titude .
S RY AND
The extremes of overjet, positive and negative, rep-
resent a disadvantage in terms of plaque accumulation
and gingivitis. However, theextent of this disadvantage
may be rather modest in the context of general behav-
ioral factors.
We would like to thank MB-. Ann Kingdon for assistance
with the d&a analysis, Mrs. Lynne Lowe for typing the manu-
script, and Mrs. Helen Draper for preparing the tables.
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