Dental Traumatology 2015; 31: 1–8; doi: 10.1111/edt.

12126

Over two hundred million injuries to

anterior teeth attributable to large overjet:
a meta-analysis

Stefano Petti Abstract – Background/Aim: The association between large overjet and
Department of Public Health and Infectious traumatic dental injuries (TDIs) to anterior teeth is documented. However,
Diseases, Sapienza University, Rome, Italy observational studies are discrepant and generalizability (i.e. external valid-
ity) of meta-analyses is limited. Therefore, this meta-analysis sought to
reconcile such discrepancies seeking to provide reliable risk estimates which
could be generalizable at global level. Material and Methods: Literature
search (years 1990–2014) was performed (Scopus, GOOGLE Scholar, Med-
line). Selected primary studies were divided into subsets: ‘primary teeth,
overjet threshold 3–4 mm’ (Primary3); ‘permanent teeth, overjet threshold
3–4 mm’ (Permanent3); ‘permanent teeth, overjet threshold 6
1 mm’
(Permanent6). The adjusted odds ratios (ORs) were extracted. To obtain
the highest level of reliability (i.e. internal validity), the pooled OR esti-
mates were assessed accounting for between-study heterogeneity, publica-
tion bias and confounding. Result robustness was investigated with
sensitivity and subgroup analyses. Results: Fifty-four primary studies
from Africa, America, Asia and Europe were included. The sampled indi-
viduals were children, adolescents and adults. Overall, there were >10 000
patients with TDI. The pooled OR estimates resulted 2.31 (95% confidence
Key words: dental trauma; tooth injury;
aetiology; prevention; permanent tooth; interval – 95CI, 1.01–5.27), 2.01 (95CI, 1.39–2.91) and 2.24 (95CI, 1.56–
primary tooth 3.21) for Primary3, Permanent3 and Permant6, respectively. Sensitivity and
subgroup analyses corroborated these estimates. Conclusions: Reliability
Correspondence to: Prof. Stefano Petti, DMD,
and generalizability of pooled ORs were high enough and made it possible
Department of Public Health and Infectious
Diseases, Sapienza University, Piazzale Aldo to assess that the fraction of global TDIs attributable to large overjet is
Moro 5, Rome I-00185, Italy 21.8% (95CI, 9.7–34.5%) and that large overjet is co-responsible for
Tel./Fax: +3906 4991 4667 235 008 000 global TDI cases (95CI, 104,760,000-372,168,000). This high
e-mail: [Link]@[Link] global burden of TDI suggests that preventive measures must be imple-
Accepted 30 June, 2014 mented in patients with large overjet.

Traumatic dental injury (TDI) is the second most com- are individual, lifestyle and environmental factors (6,
mon oral condition after dental caries affecting children 7). Individual risk factors include extra-oral conditions,
and adolescents, if not the most frequent at all in coun- such as obesity (8) and visual impairment (9, 10) and
tries where caries prevalence has drastically declined oral conditions, such as large overjet and lip incompe-
(1). Indeed, most studies report TDI prevalence as high tence (6).
as 15–30% in the permanent and in the primary denti- The association between overjet and TDI was con-
tions (2, 3). Although many TDIs are left untreated, jectured by Lewis in 1959, who found that fractures to
the costs for treatment are generally high and account anterior teeth were significantly more frequent among
for $ 2–5 million per million inhabitants per year and children with overjet larger than 3 mm (11). Since then,
require 2–9 dental visits to complete the treatment (1). many studies investigated such an association reporting
Subjects with untreated TDIs experience psychological discrepant results. For example, one Indian study
problems and quality of life impairment (2). In addi- found that subjects with overjet larger than 6 mm were
tion, TDIs are frequent among children from low not at higher TDI risk (12), while another Indian study
socio-economic strata and are suggestive of neglect and published in the same period reported that TDI risk
abuse (4, 5). For these considerations, TDI is a serious was thirteen times higher among subjects with overjet
Public Health problem. The assessment of TDI deter- larger than 3 mm (13). Therefore, the strength of the
minants is, therefore, essential to implement adequate association between overjet and TDI is not evident,
primary prevention measures aimed at decreasing expo- due to inconsistency of findings across observational
sure to the main risk factors. The TDI determinants studies (14).

© 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd 1
 16009657, 2015, 1, Downloaded from [Link] Wiley Online Library on [15/02/2025]. See the Terms and Conditions ([Link] on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
2 Petti

Systematic reviews and meta-analyses are helpful to rior teeth. Various TDI classifications were acceptable,
reconcile this disagreement between observational stud- but diagnostic criteria must be clearly provided in the
ies and to quantify the association between overjet and methods section. Examiners must be trained and/or cali-
TDI (15, 16). However, even meta-analyses may provide brated to ensure the highest possible level of reliability of
discrepant or unreliable results if they follow inappropri- diagnoses. Studies including TDIs to posterior teeth
ate or different methodologies (17, 18). This problem is were acceptable on condition that TDIs to anterior teeth
magnified in meta-analyses of observational studies (19). accounted for at least 90% of all injured teeth. Controls:
The two existing meta-analyses on the overjet-TDI asso- control patients were healthy or affected by control dis-
ciation adopted methodologies aimed at increasing the eases, that is, diseases which were not associable with
internal validity, that is, the reliability of the results and, TDI. This definition necessarily excluded dental caries,
conversely, yielded low external validity, that is, the as these conditions are associated although causality is
extent to which the results could be generalized to other not demonstrated (22). Exposure: overjet assessment and
settings and populations. Indeed, these analyses included threshold levels used to distinguish between exposed and
few primary studies from few countries (3, 20). The non-exposed subjects must be provided. Details regard-
problem of low external validity of meta-analyses is fre- ing examiner training and/or calibration must also be
quently underestimated, while it has important conse- provided. Covariate: the most important covariate
quences in applied disciplines. Indeed, although it is potential overjet confounder was lip competence/incom-
important to assess whether TDI and large overjet are petence (6). Therefore, whenever possible, the odds ratio
associated in specific settings, it is also important to (OR) adjusted for lip competence was preferred to the
assess whether such an association can be reliably crude OR. However, from the statistical point of view,
extended outside the confines of the analysis, thus help- studies which used large overjet threshold levels, such as
ing dental healthcare providers who live and work in 6 mm, could not be properly corrected for lip compe-
different settings and with different populations, to tence, because the majority of subjects with overjet
assess their patients’ risk for TDI and to decide whether higher than 6 mm concurrently show lip incompetence
to implement preventive measures. In other words, exter- and vice versa. Thus, largest overjet exposure/non-expo-
nal validity may help transform a statistical result in an sure and lip incompetence exposure/non-exposure are
important instrument usable in routine practice by dental co-linear variables (23) and, therefore, OR for largest
healthcare providers from all over the world (21). overjet could not be adjusted for lip incompetence (24).
For this reason, the aim of this study was to meta-
analyse the association between overjet and TDI to ante- Exclusion criteria
rior teeth using, as far as possible, the majority of the Duplicate studies, studies with incomplete information,
published observational studies, to obtain the highest studies which did not assess the TDI association and
degree of external validity, thus providing a consistent studies which assessed multiple TDIs were excluded.
and updated picture of the situation at global level. Potentially eligible studies were preselected on the basis
of titles and abstracts. Full texts were requested using
Materials and methods the Italian NILDE (Network Inter-Library Document
Exchange) system or contacting the corresponding
Primary studies authors. Studies with the aforementioned characteristics
A literature search, limited to the years 1990–2014, was which provided the ORs adjusted for lip competence
performed. This option led necessarily to exclude some and/or the numbers of exposed/non-exposed cases and
classic studies published before the nineties and was jus- controls were selected. ORs, standard errors and 95%
tified by the fact that the improvement of databases confidence intervals (95% CIs) were extracted or
made available the majority of the so-called grey litera- assessed.
ture (i.e. informally published material, such as studies Primary studies were split according to the type of
published by local scientific journals, theses and congress teeth under investigation and the overjet threshold used,
proceedings) published after the nineties, which is irre- thus obtaining three subsets, namely ‘primary teeth –
mediably lost before that period. Therefore, while stud- overjet threshold 3–4 mm’; ‘permanent teeth – overjet
ies available before the nineties are only those published threshold 3–4 mm’; ‘permanent teeth – overjet threshold
at high scientific level, studies available after the nineties 6
1 mm’. Few subjects in mixed dentition could be
include most of the grey literature. This discrepancy jus- mistakenly classified as having TDIs on permanent teeth,
tified the choice to limit the literature search to the last while they actually had primary teeth injured. However,
25 years. The matched terms were [(trauma OR injury) the overall fraction of primary teeth mistakenly included
AND (dental OR teeth) AND (overjet)] for Scopus and in the set of permanent teeth was minimal. As antici-
Medline through PubMed; (‘traumatic dental injury’ pated, for the study subset ‘permanent teeth – overjet
AND ‘overjet’) for GOOGLE Scholar. Additional stud- 6
1 mm’ the unadjusted ORs were used.
ies were searched using the reference lists of identified
studies. Statistical analysis

Inclusion criteria The pooled ORs for TDI due to large overjet
Eligible studies must show the following characteristics: with 95% CIs were estimated for each study subset.
Type of study: cross-sectional or case–control studies. The heterogeneity between studies was assessed and
Cases: case patients affected by any kind of TDI to ante- was used for the choice of the meta-analytic method.

© 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
 16009657, 2015, 1, Downloaded from [Link] Wiley Online Library on [15/02/2025]. See the Terms and Conditions ([Link] on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
Overjet and traumatic dental injuries 3

Primary study quality was not assessed, as study- subjects were generally children and adolescents, three
quality adjustment was considered unreliable for these studies included adults (10, 58, 83). Male-to-female ratios
studies (16, 19). were generally around 1:1, except in four studies (12, 50,
Publication bias, a serious problem in meta-analyses 65, 88). The ORs reported by the primary studies ranged
of observational studies (16, 25), was carefully investi- between 0.8 and 3.7 (primary teeth – overjet 3–4 mm);
gated, informally with the funnel plots, formally with 0.8 and 31.5 (permanent teeth – overjet 3–4 mm); and
the Egger’s (26) and the Peters’ (27) tests. When neces- 1.3 and 18.5 (permanent teeth – overjet 6
1 mm)
sary, the pooled ORs were adjusted for publication bias (Table 1).
using the trim and fill method (17, 25, 28). The high between-study heterogeneity led to use the
Sensitivity analysis to study inclusion was made to random-effects model to estimate the pooled ORs
investigate, whether the pooled OR estimates were (Appendix S2). Risk estimates uncorrected for publica-
influenced by a single study rather than all the included tion bias were 2.72 (95% CI, 1.10–6.74) for ‘primary
studies. teeth – overjet 3–4 mm’; 2.39 (95% CI, 1.62–3.51) for
Subgroup analysis was made to investigate the ‘permanent teeth – overjet 3–4 mm’; and 2.61 (95% CI,
extent of the external validity of the pooled OR esti- 1.78–3.83) for ‘permanent teeth – overjet 6
1 mm’
mates. More specifically, this analysis allowed to assess, (data not in Table). The same figures adjusted for publi-
whether the estimated pooled ORs were valid for both cation bias were 2.31 (95% CI, 1.01–5.27) for ‘primary
genders, for various age categories and for populations teeth – overjet 3–4 mm’; 2.01 (95% CI, 1.39–2.91) for
from different countries. ‘permanent teeth – overjet 3–4 mm’; and 2.24 (95% CI,
Detailed information regarding the meta-analysis 1.56–3.21) for ‘permanent teeth – overjet 6
1 mm’
methods is in Appendix S1. (Table 2).
This article followed the MOOSE guidelines for The robustness of results was corroborated by sev-
reporting meta-analyses of observational studies (15). eral elements. Namely, the use of the random-effects
A level of significance of 95% was chosen. model, which accounted for high between-study hetero-
geneity and for different degrees of study quality; the
non-significant difference between pooled OR estimates
Results
adjusted and unadjusted for publication bias; the
Of the 205 articles initially provided by the three data- results of the sensitivity analysis to study inclusion,
bases, there were 69 eligible studies, 15 of them (9, 29– which showed that no primary study had a significant
42) were excluded for various reasons, thus leaving 54 impact on the pooled OR estimates; the results of the
primary studies (8, 10, 12, 13, 23, 43–91) (Fig. 1) from subgroup analyses, which showed that these estimates
Africa, America, Asia and Europe (Table 1). Although were valid for different countries and settings, and,

205 papers (1990–2014) 119 excluded papers

184 from Scopus, 201 from GOOGLE Did not assess risk factors for traumatic
Scholar, 122 from PubMed dental injuries to anterior teeth

86 potentially eligible studies 17 excluded studies

Provided risk factors for traumatic dental Overjet not included among investigated
injuries risk factors

69 eligible studies 15 excluded studies

Overjet included among investigated risk 6 duplicate studies: Petti 1996, Soriano
factors 2004, Sgan-Cohen 2008, Bauss 2008,
Artun 2009, de Oliveira-Filho, 2014
6 incomplete data: Hohoff 2003,
Cecconello 2007, Gupta 2011, Bhat 2011,
54 primary studies
Ahlawat 2013, Zhang, 2014
2 did not associate traumatic dental
injuries and overjet: Kahabuka 2009,
Altun 2009
1 case subjects with multiple traumatic
dental injuries: Glendor 2000
Fig. 1. Flow chart of primary study
selection procedure.

© 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
 16009657, 2015, 1, Downloaded from [Link] Wiley Online Library on [15/02/2025]. See the Terms and Conditions ([Link] on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
4 Petti

Table 1. List of primary studies included in the three study subsets (listed in chronological order)
First Author, Year (ref.) Country Age range Gender (% Males) OR 95% CI
Primary teeth – Overjet threshold 3–4 mm
Al-Majed, 2001 (50) Saudi Arabia 5–6 years 100% 0.84 0.50–1.41
Robson, 2009 (23) Brazil 0–5 years 48.4% 3.72 2.42–5.72
Feldens, 2010 (72) Brazil 3–5 years 52.8% 2.09 1.52–2.88
Bonini, 2012 (77) Brazil 3–5 years 49.2% 2.43 1.68–3.53
Norton, 2012 (80) Ireland 1–6 years 50.1% 2.04 1.48–2.80
Piovesan, 2012 (82) Brazil 1–5 years 54.4% 1.63 1.06–2.53
Siqueira, 2013 (91) Brazil 3–5 years 55.2% 1.54 1.22–1.94
Permanent teeth – Overjet threshold 3–4 mm
Forsberg, 1993 (44) Sweden 7–15 years 50.5% 1.70 1.30–2.21
Otuyemi, 1994 (45) Nigeria 12 years NA 4.47 2.96–6.77
Burden, 1995 (46) Ireland 11–12 years NA 2.77 1.98–3.88
Stokes, 1995 (47) Singapore 7–18 years 76.4% 0.80 0.32–2.02
Petti, 1997 (8) Italy 6–11 years 48.7% 1.68 1.21–2.33
Al-Majed, 2001 (50) Saudi Arabia 12–14 years 100% 1.50 1.12–2.01
Tapias, 2003 (55) Spain 10 years 52.3% 1.84 1.13–2.98
Bauss, 2004 (56) Germany 11–15 years 46.5% 1.81 1.21–2.69
Grimm, 2004 (57) Brazil 5–12 years 49.4% 1.77 1.39–2.27
Shulman, 2004 (58) US 6–50 years1 46.9% 1.71 1.48–1.99
Al-Khateeb, 2005 (60) Jordan 13–15 years 38.5% 2.48 1.65–3.71
Artun, 2005 (61) Kuwait 13–14 years 49.8% 1.26 0.95–1.68
Pattussi, 2005 (62) Brazil 14–15 years 52.3% 1.52 0.97–2.44
Sgan-Cohen, 2005 (63) Israel 10–12 years 50.1% 1.50 1.00–2.24
Baldava, 2007 (65) India 14–16 years 100% 3.59 1.98–6.49
Cavalcanti, 2009 (69) Brazil 7–12 years 50.9% 2.66 1.63–431
Borzabadi-Farahani, 2010 (71) Iran 11–14 years 49.6% 2.83 1.49–5.37
Ramos-Jorge, 2011 (74) Brazil 12–15 years 46.5% 2.00 1.20–3.34
Varghese, 2011 (10) India 10–29 years2 67.7% 14.77 0.72–301.58
Altun, 2012 (76) Turkey 7–15 years 75.2% 2.52 1.16–5.47
Bendgude, 2012 (12) India 11–17 years 0.0% 1.96 1.18–3.27
Jorge, 2012 (78) Brazil 15–19 years 39.5% 4.94 3.13–7.78
Martins, 2012 (79) Brazil 7–14 years 46.6% 2.20 1.20–3.90
Patel, 2012 (81) India 8–13 years 50.4% 3.43 2.53–4.63
Agrawal, 2013 (83) India 10–29 years 68.0% 31.50 9.25–107.27
Ankola, 2013 (13) India 6–11 years 49.3% 13.21 11.76–14.84
Francisco, 2013 (85) Brazil 9–14 years NA 1.78 1.18–2.69
Marinho, 2013 (86) Portugal 15–19 years 40.5% 1.70 0.90–3.00
Oliveira-Filho, 2013 (87) Brazil 14–19 years 43.4% 1.63 1.16–2.30
Prabhu, 2013 (88) India 10–16 years 100% 9.20 5.28–16.01
Rajab, 2013 (89) Jordan 12 years 47.2% 1.84 1.25–2.70
Permanent teeth – Overjet threshold 6
1 mm
Hunter, 1990 (43) UK 11–12 years 50.4% 1.63 1.12–2.37
Forsberg, 1993 (44) Sweden 7–15 years 50.5% 1.41 1.04–1.91
Burden, 1995 (46) Ireland 11–12 years NA 2.30 1.48–3.55
Marcenes, 1999 (48) Syria 9–12 years 58.9% 2.07 1.02–4.21
Brin, 2000 (49) Israel 9–13 years 43.5% 2.29 1.15–4.55
Al-Majed, 2001 (50) Saudi Arabia 12–14 years 100% 1.42 0.64–3.13
Cortes, 2001 (51) Brazil 9–14 years 46.7% 1.86 1.48–2.32
Marcenes, 2001 (52) Brazil 12 years 49.5% 1.48 0.89–2.45
Marcenes, 2001 (53) UK 14 years 47.3% 1.54 1.25–1.91
Odoi, 2002 (54) UK 7–15 years 58.8% 2.18 1.02–4.64
Shulman, 2004 (58) US 6–50 years1 46.9% 2.27 1.46–3.53
Traebert, 2004 (59) Brazil 11–13 years 51.9% 1.64 1.18–2.28
Al-Khateeb, 2005 (60) Jordan 13–15 years 38.5% 4.22 2.43–7.32
Artun, 2005 (61) Kuwait 13–14 years 49.8% 2.39 1.53–3.73
Sgan-Cohen, 2005 (63) Israel 10–12 years 50.1% 2.98 1.56–5.72
Traebert, 2006 (64) Brazil 12 years 48.1% 4.45 1.99–9.95
Baldava, 2007 (65) India 14–16 years 100% 3.39 1.71–6.71
Soriano, 2007 (66) Brazil 12 years 50.3% 3.22 2.13–4.86
Noueihed, 2008 (67) Canada 8–10 years 55.9% 2.92 1.43–5.96
Ramos-Jorge, 2008 (68) Brazil 11–13 years 35.9% 1.90 1.03–3.50
Bendo, 2010 (70) Brazil 11–14 years 41.7% 1.98 1.20–3.26
Borzabadi-Farahani, 2010 (71) Iran 11–14 years 49.6% 2.28 0.63–8.23
Livny, 2010 (73) Palestinia 11–12 years 49.4% 18.48 11.53–29.64
Taiwo, 2011 (75) Nigeria 12 years 57.2% 2.90 1.07–7.91
Bendgude, 2012 (12) India 11–17 years 0.0% 2.32 0.97–5.54

© 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
 16009657, 2015, 1, Downloaded from [Link] Wiley Online Library on [15/02/2025]. See the Terms and Conditions ([Link] on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
Overjet and traumatic dental injuries 5

Table 1. Continued
First Author, Year (ref.) Country Age range Gender (% Males) OR 95% CI
Patel, 2012 (81) India 8–13 years 50.4% 3.92 2.72–5.64
Dame-Teixeira, 2013 (84) Brazil 12 years 50.4% 1.35 1.00–1.83
Prabhu, 2013 (88) India 10–16 years 100% 7.56 4.11–13.89
Schatz, 2013 (90) Switzerland 6–13 years 52.6% 4.03 2.79–5.81
1
children/adolescents, 42.7%; adults, 57,3%.
2
children/adolescents, 60.6%, adults, 39.4%.

Table 2. Pooled ORs adjusted for publication bias of the Table 3. Estimated fraction of global TDIs (population
association between large overjet and TDIs to anterior teeth attributable fraction – PAF) on permanent teeth attributable
to large overjet
Type of teeth Overjet threshold Pooled OR 95% CI
Overjet threshold Prevalence PAF 95% CI
Primary 3–4 mm 2.311 1.01–5.27
Permanent 3–4 mm 2.011 1.39–2.91 3–4 mm 27.53% 21.76%1
9.70–34.46%
Permanent 6
1 mm 2.241 1.56–3.21 6
1 mm 9.13% 10.17%1 4.86–16.79
1 1
Statistically significant at 95% level. Statistically significant at 95% level.

therefore, for different ethnic, age and gender groups present analysis sought to yield the highest possible
(Appendix S2). level of generalizability. Indeed, 54 primary studies
were included, case patients with TDI were more than
Discussion 10 000. They came from Europe, America, Asia and
Africa and not just from Europe and America, and
The technical aspects regarding the main limits of the included adults and not only children and adolescents.
present meta-analysis of observational studies (16, 92) Thus, if the pooled ORs reported here have the limit to
in conformity with the MOOSE checklist (15) are yield wide confidence intervals, they have the indisput-
reported in Appendix S3. able merit to be generalizable to many contexts and
Dental healthcare providers, public health experts settings.
and policy makers face two important questions as An important consequence of generalizable pooled
they read meta-analyses: is the report believable, and, ORs is that they make it possible to assess the fraction
if so, how relevant is it? Believable meta-analyses yield of global TDIs due to large overjet.
high internal (i.e. reliability) and external (i.e. generaliz- The formula to calculate the so-called population
ability) validities, while relevant analyses report strong attributable fraction (PAF) is (94)
exposure–outcome associations (i.e. high pooled OR
estimates) with clinically appreciable consequences (14, PAF ¼ ½pexp ðOR  1Þ=½1 þ pexp ðOR  1Þ
93). The two previously published meta-analyses
focused on internal validity; therefore, to minimize where pexp is the pooled global prevalence of subjects
between-study heterogeneity, they excluded several with large overjet and was estimated applying the fixed-
observational studies. Indeed, the pooled ORs for over- effects method to the cross-sectional studies included in
jet thresholds of 3 and 6 mm reported by Nguyen and the present meta-analysis, which are typically prevalence
colleagues were based on only four and three studies, studies. The PAF estimates were 21.8% and 10.2% for
respectively (20), while the pooled OR for overjet larger permanent teeth and overjet threshold 3–4 mm and
than 5 mm in Latin America reported by Aldrigui and 6
1 mm, respectively (Table 3).
colleagues was based on eleven studies (3). The high These PAF estimates made it possible to assess the
level of internal validity in these analyses was demon- number of TDIs that can be totally or partly attribut-
strated by the confidence intervals of the pooled OR able to large overjet. First, global TDI prevalence was
estimates, which were narrower than those reported in estimated using well-designed reviews and choosing the
the present study. The limit of these meta-analyses was lowest plausible limit, to obtain a conservative and reli-
that internal and external validity are inversely associ- able estimate (2, 3). This measure was taken to com-
ated. Therefore, pooled ORs assessed using few pri- pensate the fact that PAF generally tends to
mary studies cannot be considered valid for different overestimate the true attributable fraction (94, 95).
settings, populations and contexts than those of the Second, the global number of TDIs was assessed by
included studies. For example, the pooled ORs multiplying global TDI prevalence with the world
reported by Nguyen and colleagues, and Aldrigui and population estimate (Population Reference Bureau,
colleagues (3, 20) cannot be generalized to adults or to available at, [Link] accessed March 13th,
African or Asian ethnic groups. 2014). Third, the number of global TDIs attributable
To provide a useful instrument for the assessment of to large overjet was obtained by multiplying the global
TDI risk at individual and population levels directed to number of TDIs with the PAF estimate for overjet
dental healthcare providers from all over the world, the threshold of 3 mm.

© 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
 16009657, 2015, 1, Downloaded from [Link] Wiley Online Library on [15/02/2025]. See the Terms and Conditions ([Link] on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
6 Petti

The most reliable world TDI prevalence was set at Andersson L, editors. Traumatic dental injuries. A manual,
15%. With a global population of 7 200 000 000, the 3rd edn. Chichester: Wiley-Blackwell; 2011. p. 8–9.
number of people living with at least one TDI of any 8. Petti S, Cairella G, Tarsitani G. Childhood obesity: a risk
factor for traumatic injuries to anterior teeth. Endod Dent
kind (e.g. single or multiple, mild or severe, treated or
Traumatol 1997;13:285–8.
untreated, etc.) resulted 1 080 000 000. Therefore, 9. Bhat N, Agrawal A, Nagrajappa R, Roy SS, Singh K, Chaudh-
235 008 000 (95% CI, 104,760,000-372,168,000) people ary H et al. Teeth fracture among visually impaired and sighted
in the world live with TDIs partly or totally attribut- children of 12 and 15 years age groups of Udaipur city, India–a
able to large overjet. comparative study. Dent Traumatol 2011;27:389–92.
10. Varghese RK, Agrawal A, Mitra A, Fating C. Anterior teeth
fracture among visually impaired individuals, India. J Adv
Conclusion Oral Res 2011;2:39–44.
11. Lewis TE. Incidence of fractured anterior teeth as related to
In conclusion, the present meta-analysis of observa-
their protrusion. Angle Orthod 1959;29:128–31.
tional studies showed that large overjet may double or 12. Bendgude V, Akkareddy B, Panse A, Singh R, Metha D,
even triple the risk for TDI to anterior primary and Jawale B et al. Correlation between dental traumatic injuries
permanent teeth and that, at global level, large overjet and overjet among 11 to 17 years Indian girls with Angle’s
is partly responsible for 100–300 million TDIs. These class I molar relation. J Contemp Dent Pract 2012;13:142–6.
figures do not require further comments and corrobo- 13. Ankola AV, Hebbal M, Sharma R, Nayak SS. Traumatic
rate the idea that the global burden of TDI is very high dental injuries in primary school children of South India–a
(1, 2) and that large overjet has a significantly high report from district-wide oral health survey. Dent Traumatol
2013;29:134–8.
impact on this figure. The reported pooled ORs help
14. Petti S. Why guidelines for early childhood caries prevention
assess the patients’ risk for TDI and, therefore, to could be ineffective amongst children at high risk. J Dent
decide whether preventive measures must be taken to 2010;38:946–55.
decrease such a risk. These measures may range from 15. Stroup DF, Berlin JA, Morton SC, Olkin I, Williamson GD,
orthodontic treatment (96, 97), to mouth protection for Rennie D et al. Meta-analysis of observational studies in epi-
exposed individuals at high TDI risk (98) and tutors’ demiology: a proposal for reporting. Meta-analysis of Obser-
counselling to increase their awareness towards their vational Studies in Epidemiology (MOOSE) group. JAMA
children proneness to TDI while they are playing or 2000;283:2008–12.
16. Sutton A, Abrams KR, Jones DR, Sheldon TA, Song F.
are at home (99). Well-designed clinical trials and Methods for meta-analysis in medical research. Chichester:
good-quality systematic reviews are necessary to assess Wiley & Sons; 2000.
the effectiveness of these measures to decrease the risk 17. Sutton AJ, Duval SJ, Tweedie RL, Abrams KR, Jones DR.
for dental injuries in subjects with large overjet. Empirical assessment of effect of publication bias on
meta-analyses. BMJ 2000;320:1574–7.
18. Delgado-Rodrıguez M. Systematic reviews of meta-analyses:
Acknowledgements applications and limitations. J Epidemiol Community Health
I am indebted with Dr. Ambra Gull
a, DMD, for her 2006;60:90–2.
19. Thompson S, Ekelund U, Jebb S, Lindroos AK, Mander A,
precious help to collect the primary studies. Sharp S et al. A proposed method of bias adjustment for
meta-analyses of published observational studies. Int J
Conflict of interest Epidemiol 2011;40:765–77.
20. Nguyen QV, Bezemer PD, Habets L, Prahl-Andersen B. A
None declared. systematic review of the relationship between overjet size and
traumatic dental injuries. Eur J Orthod 1999;21:503–15.
21. Steckler A, McLeroy KR. The importance of external valid-
References ity. Am J Public Health 2008;98:9–10.
22. Fakhruddin KS, Lawrence HP, Kenny DJ, Locker D. Etiol-
1. Andersson L. Epidemiology of traumatic dental injuries.
ogy and environment of dental injuries in 12- to 14-year-old
J Endod 2013;39:S2–5.
Ontario schoolchildren. Dent Traumatol 2008;24:305–8.
2. Glendor U. Epidemiology of traumatic dental injuries–a 12
23. Robson F, Ramos-Jorge ML, Bendo CB, Vale MP, Paiva
year review of the literature. Dent Traumatol 2008;24:603–11.
SM, Pordeus IA. Prevalence and determining factors of trau-
3. Aldrigui JM, Jabbar NS, Bonecker M, Braga MM, Wander-
matic injuries to primary teeth in preschool children. Dent
ley MT. Trends and associated factors in prevalence of dental
Traumatol 2009;25:118–22.
trauma in Latin America and Caribbean: a systematic review
24. Bagley SC, White H, Golomb BA. Logistic regression in the
and meta-analysis. Community Dent Oral Epidemiol
medical literature: standards for use and reporting, with par-
2014;42:30–42.
ticular attention to one medical domain. J Clin Epidemiol
4. Kellogg N; American Academy of Pediatrics Committee on,
2001;54:979–85.
Child Abuse and Neglect. Oral and dental aspects of child
25. Peters JL, Sutton AJ, Jones DR, Abrams KR, Rushton L.
abuse and neglect. Pediatrics 2005;116:1565–8.
Performance of the trim and fill method in the presence of
5. Garbin CA, Guimar~aes e Queiroz AP, Rovida TA, Garbin
publication bias and between-study heterogeneity. Stat Med
AJ. Occurrence of traumatic dental injury in cases of domes-
2007;26:4544–62.
tic violence. Braz Dent J 2012;23:72–6.
26. Egger M, Davey Smith G, Schneider M, Minder C. Bias in
6. Glendor U. Aetiology and risk factors related to traumatic
meta-analysis detected by a simple, graphical test. BMJ
dental injuries–a review of the literature. Dent Traumatol
1997;315:629–34.
2009;25:19–31.
27. Peters JL, Sutton AJ, Jones DR, Abrams KR, Rushton L.
7. Andreasen JO, Bakland LK, Flores MT, Andreasen FM,
Comparison of two methods to detect publication bias in
Andersson L. Epidemiology of traumatic dental injuries. In:
meta-analysis. JAMA 2006;295:676–80.
Andreasen JO, Bakland LK, Flores MT, Andreasen FM,

© 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
 16009657, 2015, 1, Downloaded from [Link] Wiley Online Library on [15/02/2025]. See the Terms and Conditions ([Link] on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
Overjet and traumatic dental injuries 7

28. Duval S, Tweedie R. Trim and fill: a simple funnel-plot-based 49. Brin I, Fuks A, Guelmann M, Hirschfeld Z. Long-term
method of testing and adjusting for publication bias in follow-up of conservative treatment of severely traumatized
meta-analysis. Biometrics 2000;56:455–63. maxillary incisors. Endod Dent Traumatol 1997;13:190–2.
29. Petti S, Tarsitani G. Traumatic injuries to anterior teeth in 50. Al-Majed I, Murray JJ, Maguire A. Prevalence of dental
Italian schoolchildren: prevalence and risk factors. Endod trauma in 5-6- and 12-14-year-old boys in Riyadh, Saudi Ara-
Dent Traumatol 1996;12:294–7. bia. Dent Traumatol 2001;17:153–8.
30. Glendor U, Koucheki B, Halling A. Risk evaluation and type 51. Cortes MI, Marcenes W, Sheiham A. Prevalence and corre-
of treatment of multiple dental trauma episodes to permanent lates of traumatic injuries to the permanent teeth of school-
teeth. Endod Dent Traumatol 2000;16:205–10. children aged 9–14 years in Belo Horizonte, Brazil. Dent
31. Hohoff A, Stamm T, Goedde M, Lippold C, Ehmer U. Traumatol 2001;17:22–6.
Trauma of the front teeth in childhood in relation to ortho- 52. Marcenes W, Zabot NE, Traebert J. Socio-economic corre-
dontic diagnosis. J Dent Res 2003;82:B44. lates of traumatic injuries to the permanent incisors in school-
32. Bauss O, Freitag S, R€ ohling J, Rahman A. Influence of over- children aged 12 years in Blumenau, Brazil. Dent Traumatol
jet and lip coverage on the prevalence and severity of incisor 2001;17:222–6.
trauma. J Orofac Orthop 2008;69:402–10. 53. Marcenes W, Murray S. Social deprivation and traumatic
33. Soriano EP, Caldas AF Jr, G oes PS. Risk factors related to dental injuries among 14-year-old schoolchildren in Newham,
traumatic dental injuries in Brazilian schoolchildren. Dent London. Dent Traumatol 2001;17:17–21.
Traumatol 2004;20:246–50. 54. Odoi R, Croucher R, Wong F, Marcenes W. The relationship
34. Cecconello R, Traebert J. Traumatic dental injuries in adoles- between problem behaviour and traumatic dental injury
cents from a town in southern Brazil: a cohort study. Oral amongst children aged 7–15 years old. Community Dent Oral
Health Prev Dent 2007;5:321–6. Epidemiol 2002;30:392–6.
35. Sgan-Cohen HD, Yassin H, Livny A. Dental trauma among 55. Tapias MA, Jimenez-Garcıa R, Lamas F, Gil AA. Prevalence
5th and 6th grade Arab schoolchildren in Eastern Jerusalem. of traumatic crown fractures to permanent incisors in a child-
Dent Traumatol 2008;24:458–61. hood population: M ostoles, Spain. Dent Traumatol
36. Altun C, Ozen B, Esenlik E, Guven G, G€ urb€
uz T, Acikel C 2003;19:119–22.
et al. Traumatic injuries to permanent teeth in Turkish chil- 56. Bauss O, R€ ohling J, Schwestka-Polly R. Prevalence of trau-
dren, Ankara. Dent Traumatol 2009;25:309–13. matic injuries to the permanent incisors in candidates for
37. Artun J, Al-Azemi R. Social and behavioral risk factors for orthodontic treatment. Dent Traumatol 2004;20:61–6.
maxillary incisor trauma in an adolescent Arab population. 57. Grimm S, Fraz~ao P, Antunes JL, Castellanos RA, Narvai
Dent Traumatol 2009;25:589–93. PC. Dental injury among Brazilian schoolchildren in the state
38. Kahabuka FK, Mugonzibwa EA. Risk factors for injuries to of S~ao Paulo. Dent Traumatol 2004;20:134–8.
maxillary permanent incisors and upper lip among schoolchil- 58. Shulman JD, Peterson J. The association between incisor
dren in Dar es Salaam, Tanzania. Int J Paediatr Dent trauma and occlusal characteristics in individuals 8–50 years
2009;19:148–54. of age. Dent Traumatol 2004;20:67–74.
39. Gupta S, Kumar-Jindal S, Bansal M, Singla A. Prevalence of 59. Traebert J, Almeida IC, Garghetti C, Marcenes W. Preva-
traumatic dental injuries and role of incisal overjet and inade- lence, treatment needs, and predisposing factors for traumatic
quate lip coverage as risk factors among 4–15 years old gov- injuries to permanent dentition in 11-13-year-old schoolchil-
ernment school children in Baddi-Barotiwala Area, Himachal dren. Cad Saude Publica 2004;20:403–10.
Pradesh, India. Med Oral Patol Oral Cir Bucal 2011;16: 60. Al-Khateeb S, Al-Nimri K, Alhaija EA. Factors affecting
e960–5. coronal fracture of anterior teeth in North Jordanian chil-
40. Ahlawat B, Kaur A, Thakur G, Mohindroo A. Anterior dren. Dent Traumatol 2005;21:26–8.
tooth trauma: a most neglected oral health aspect in adoles- 61. Artun J, Behbehani F, Al-Jame B, Kerosuo H. Incisor
cents. Indian J Oral Sci 2013;4:31–7. trauma in an adolescent Arab population: prevalence, sever-
41. Zhang Y, Zhu Y, Su W, Zhou Z, Jin Y, Wang X. A retro- ity, and occlusal risk factors. Am J Orthod Dentofacial Ort-
spective study of pediatric traumatic dental injuries in Xi’an, hop 2005;128:347–52.
China. Dent Traumatol 2014;30:211–5. 62. Pattussi MP, Hardy R, Sheiham A. Neighborhood social cap-
42. de Oliveira Filho PM, Jorge KO, Paiva PC, Ferreira EF, ital and dental injuries in Brazilian adolescents. Am J Public
Ramos-Jorge ML, Zarzar PM. The prevalence of dental Health 2006;96:1462–8.
trauma and its association with illicit drug use among adoles- 63. Sgan-Cohen HD, Megnagi G, Jacobi Y. Dental trauma and
cents. Dent Traumatol 2014;30:122–7. its association with anatomic, behavioral, and social variables
43. Hunter ML, Hunter B, Kingdon A, Addy M, Dummer PM, among fifth and sixth grade schoolchildren in Jerusalem.
Shaw WC. Traumatic injury to maxillary incisor teeth in a Community Dent Oral Epidemiol 2005;33:174–80.
group of South Wales school children. Endod Dent Trauma- 64. Traebert J, Bittencourt DD, Peres KG, Peres MA, de
tol 1990;6:260–4. Lacerda JT, Marcenes W. Aetiology and rates of treatment
44. Forsberg CM, Tedestam G. Etiological and predisposing fac- of traumatic dental injuries among 12-year-old school chil-
tors related to traumatic injuries to permanent teeth. Swed dren in a town in southern Brazil. Dent Traumatol
Dent J 1993;17:183–90. 2006;22: 173–8.
45. Otuyemi OD. Traumatic anterior dental injuries related to 65. Baldava P, Anup N. Risk factors for traumatic dental injuries
incisor overjet and lip competence in 12-year-old Nigerian in an adolescent male population in India. J Contemp Dent
children. Int J Paediatr Dent 1994;4:81–5. Pract 2007;8:35–42.
46. Burden DJ. The influence of social class, gender, and peers 66. Soriano EP, Caldas Ade F Jr, Diniz De Carvalho MV,
on the uptake of orthodontic treatment. Eur J Orthod Amorim Filho Hde A. Prevalence and risk factors related to
1995;17:199–203. traumatic dental injuries in Brazilian schoolchildren. Dent
47. Stokes AN, Loh T, Teo CS, Bagramian RA. Relation Traumatol 2007;23:232–40.
between incisal overjet and traumatic injury: a case control 67. Noueihed C. An investigation of the effect of neighbourhood
study. Endod Dent Traumatol 1995;11:2–5. characteristics on traumatic dental injuries among a sample
48. Marcenes W, Al Beiruti N, Tayfour D, Issa S. Epidemiology of Quebec children. MSci Thesis. Montreal: Mc Gill Univer-
of traumatic injuries to the permanent incisors of 9-12-year-old sity; 2008.
schoolchildren in Damascus, Syria. Endod Dent Traumatol 68. Ramos-Jorge ML, Peres MA, Traebert J, Ghisi CZ, de Paiva
1999;15:117–23. SM, Pordeus IA et al. Incidence of dental trauma among

© 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
 16009657, 2015, 1, Downloaded from [Link] Wiley Online Library on [15/02/2025]. See the Terms and Conditions ([Link] on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
8 Petti

adolescents: a prospective cohort study. Dent Traumatol dren: prevalence, severity, and risk indicators. Dent Trauma-
2008;24:159–63. tol 2013;29:52–8.
69. Cavalcanti AL, Bezerra PK, de Alencar CR, Moura C. Trau- 85. Francisco SS, Filho FJ, Pinheiro ET, Murrer RD, de Jesus
matic anterior dental injuries in 7- to 12-year-old Brazilian Soares A. Prevalence of traumatic dental injuries and associ-
children. Dent Traumatol 2009;25:198–202. ated factors among Brazilian schoolchildren. Oral Health
70. Bendo CB, Paiva SM, Oliveira AC, Goursand D, Torres CS, Prev Dent 2013;11:31–8.
Pordeus IA et al. Prevalence and associated factors of trau- 86. Marinho ACMR, Manso MC, Colares V, de Andrade DJC.
matic dental injuries in Brazilian schoolchildren. J Public Preval^encia de traumatismo dentario e fatores associados em
Health Dent 2010;70:313–18. adolescentes no concelho do Porto. Rev Port Estomatol Med
71. Borzabadi-Farahani A, Borzabadi-Farahani A, Eslamipour F. Dent Cir Maxilofac 2013;54:143–9.
An investigation into the association between facial profile 87. Oliveira Filho PM, Jorge KO, Ferreira EF, Ramos-Jorge
and maxillary incisor trauma, a clinical non-radiographic ML, Tataounoff J, Zarzar PM. Association between dental
study. Dent Traumatol 2010;26:403–8. trauma and alcohol use among adolescents. Dent Traumatol
72. Feldens CA, Kramer PF, Ferreira SH, Spiguel MH, Marque- 2013;29:372–7.
zan M. Exploring factors associated with traumatic dental 88. Prabhu A, Rao AP, Govindarajan M, Reddy V, Krishnaku-
injuries in preschool children: a Poisson regression analysis. mar R, Kalaiperumal S. Attributes of dental trauma in a
Dent Traumatol 2010;26:143–8. school population with active sports involvement. Asian
73. Livny A, Sgan-Cohen HD, Junadi S, Marcenes W. Traumatic J Sports Med 2013;4:190–4.
dental injuries and related factors among sixth grade school- 89. Rajab LD, Baqain ZH, Ghazaleh SB, Sonbol HN, Hamdan
children in four Palestinian towns. Dent Traumatol MA. Traumatic dental injuries among 12-year-old school-
2010;26:422–6. child. Oral Health Prev Dent 2013;11:105–12.
74. Ramos-Jorge ML, Tataounoff J, Corr^ea-Faria P, Alc^antara 90. Schatz JP, Hakeberg M, Ostini E, Kiliaridis S. Prevalence of
CE, Ramos-Jorge J, Marques LS. Non-accidental collision traumatic injuries to permanent dentition and its association
followed by dental trauma: associated factors. Dent Trauma- with overjet in a Swiss child population. Dent Traumatol
tol 2011;27:442–5. 2013;29:110–14.
75. Taiwo OO, Jalo HP. Dental injuries in 12-year old Nigerian 91. Siqueira MB, Gomes MC, Oliveira AC, Martins CC, Granvil-
students. Dent Traumatol 2011;27:230–4. le-Garcia AF, Paiva SM. Predisposing factors for traumatic
76. Altun C, Guven G, Akgun OM, Acikel C. Dental injuries dental injury in primary teeth and seeking of post-trauma
and attention-deficit/hyperactivity disorder in children. Spec care. Braz Dent J 2013;24:647–54.
Care Dentist 2012;32:184–9. 92. Delgado-Rodrıguez M, Llorca J. Bias. J Epidemiol Commu-
77. Bonini GC, B€ onecker M, Braga MM, Mendes FM. Com- nity Health 2004;58:635–41.
bined effect of anterior malocclusion and inadequate lip cov- 93. Grimes DA, Schultz KF. Bias and causal associations in
erage on dental trauma in primary teeth. Dent Traumatol observational research. Lancet 2002;359:248–52.
2012;28:437–40. 94. Rowe AK, Powell KE, Flanders WD. Why population attrib-
78. Jorge KO, Oliveira Filho PM, Ferreira EF, Oliveira AC, Vale utable fractions can sum to more than one. Am J Prev Med
MP, Zarzar PM. Prevalence and association of dental injuries 2004;26:243–9.
with socioeconomic conditions and alcohol/drug use in ado- 95. Petti S, Masood M, Scully C. The magnitude of tobacco
lescents between 15 and 19 years of age. Dent Traumatol smoking-betel quid chewing-alcohol drinking interaction
2012;28:136–41. effect on oral cancer in South-East Asia. A meta-analysis of
79. Martins VM, Sousa RV, Rocha ES, Leite RB, Paiva SM, observational studies. PLoS ONE 2013;8:e78999.
Granville-Garcia AF. Dental trauma among Brazilian school- 96. Chen DR, McGorray SP, Dolce C, Wheeler TT. Effect of
children: prevalence, treatment and associated factors. Eur early Class II treatment on the incidence of incisor trauma.
Arch Paediatr Dent 2012;13:232–7. Am J Orthod Dentofacial Orthop 2011;140:e155–60.
80. Norton E, O’Connell AC. Traumatic dental injuries and their 97. British Orthodontic Society, Clinical Standards Committee.
association with malocclusion in the primary dentition of The justification for orthodontic treatment. London: British
Irish children. Dent Traumatol 2012;28:81–6. Orthodontic Society; 2009.
81. Patel MC, Sujan SG. The prevalence of traumatic dental inju- 98. American Academy of Pediatric Dentistry. Oral Health Poli-
ries to permanent anterior teeth and its relation with predis- cies. Policy on Prevention of Sports-related Orofacial Injuries.
posing risk factors among 8–13 years school children of [updated 2013; cited 2013 December 2]. Available at: http://
Vadodara city: an epidemiological study. J Indian Soc Pedod [Link]/media/Policies_Guidelines/P_Sports.pdf.
Prev Dent 2012;30:151–7. 99. Petti S, Scully C. Oral cancer knowledge and awareness: pri-
82. Piovesan C, Guedes RS, Casagrande L, Ardenghi TM. Socio- mary and secondary effects of an information leaflet. Oral
economic and clinical factors associated with traumatic dental Oncol 2007;43:408–15.
injuries in Brazilian preschool children. Braz Oral Res
2012;26:464–70.
83. Agrawal A, Bhatt N, Chaudhary H, Singh K, Mishra P, Asawa Supporting information
K. Prevalence of anterior teeth fracture among visually
impaired individuals, India. Indian J Dent Res 2013;24:664–8. Additional supporting information may be found in the
84. Dame-Teixeira N, Alves LS, Susin C, Maltz M. Traumatic
dental injury among 12-year-old South Brazilian schoolchil-
online version of this article at the publisher’s website.

© 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd