Table of Contents  
Year : 2022  |  Volume : 14  |  Issue : 1  |  Page : 28-34

Multilayer Perceptron to Assess the Impact of Anatomical Risk Factors on Traumatic Dental Injuries: An Advanced Statistical Approach of Artificial Intelligence in Dental Traumatology

1 Private Pediatric Dental Practice, Aligarh, Uttar Pradesh, India
2 Department of Pediatric and Preventive Dentistry, Dr. Ziauddin Ahmad Dental College and Hospital, Aligarh Muslim University, Aligarh, Uttar Pradesh, India

Date of Submission06-Feb-2021
Date of Decision13-May-2022
Date of Acceptance23-May-2022
Date of Web Publication05-Aug-2022

Correspondence Address:
Dr. Mohammad Kamran Khan
Specialist Consultant Pedodontist, Hamdard Nagar-A, Civil Lines, Aligarh, Uttar Pradesh
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jofs.jofs_42_22

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Introduction: Traumatic dental injuries (TDIs) are the public dental health concern, with variable prevalence reported worldwide. Although, TDI is not a disease rather, it is a result of various risk factors. This study was performed to assess the influence of anatomical risk factors such as accentuated overjet, overbite, molar relationship, and lip competency in determining the number of traumatized teeth per affected individual by using the advanced statistical method of multilayer perceptron (MLP) model of deep learning algorithm of artificial intelligence (AI). Materials and Methods: A cross-sectional study consisted of 1000 school children (boys and girls) of index age groups between 12 and 15 years selected through multistage sampling technique. Orofacial anatomical risk factors associated with TDI were statistically analyzed by MLP model of deep learning algorithm of AI using IBM SPSS Modeler software (version 18, 2020). Results: MLP method revealed results in terms of normalized importance as overbite (100%) was the strongest risk factor for the occurrence of TDI in number of teeth of affected participants, followed by molar relationship (90.2%), overjet (87.7%), and the lip competency was found as the weakest risk factor. Conclusion: Using the MLP as statistical method, overbite was found as the strongest anatomical risk factor in determining the number of traumatized teeth per affected individual as compared to molar relationship, overjet, and lip competence.

Keywords: Advanced statistical analysis, anatomical risk factors, artificial intelligence (AI), artificial neural network (ANN), cross-sectional study, deep learning, machine learning, modern statistical methods, multilayer perceptron (MLP), traumatic dental injuries

How to cite this article:
Khan MK, Jindal MK. Multilayer Perceptron to Assess the Impact of Anatomical Risk Factors on Traumatic Dental Injuries: An Advanced Statistical Approach of Artificial Intelligence in Dental Traumatology. J Orofac Sci 2022;14:28-34

How to cite this URL:
Khan MK, Jindal MK. Multilayer Perceptron to Assess the Impact of Anatomical Risk Factors on Traumatic Dental Injuries: An Advanced Statistical Approach of Artificial Intelligence in Dental Traumatology. J Orofac Sci [serial online] 2022 [cited 2022 Dec 3];14:28-34. Available from:

  Introduction Top

Oral health is also an integral part of the individual’s overall health and hence, any disease or trauma to oral and dental tissues influences the overall health of the individual. Traumatic dental injuries (TDIs) are the public dental health concern, with variable prevalence reported worldwide (6%–59%).[1] Earlier, it was assumed that dental injuries would most likely exceed dental caries and periodontal diseases[2] and now that seem to be true by seeing their differences in prevalence in recent studies. TDIs are the most commonly affected injuries in children and adolescents, making them highly susceptible age group for dental trauma.[3] It has been observed that such dental injuries are more common in certain age groups, but no individual can ever be at zero risk through their daily living activities.[1]

Although, TDI is not a disease, it is a result of various risk factors related to an individual’s life.[1] The consequences of such injuries not only affect an individual physically or economically but also increases the psychosocial burden indefinably.[1] TDIs are costly and time consuming to manage as compared to other bodily injuries in emergency hospitals.[4] The average number of visits needed to treat such injuries are 1.9 to 9.1 while for other bodily traumas are just 1.5.[4]

The approach for managing dental caries and oral diseases has evolved from “treating the lesions” to “managing risk factors” associated with them. Likewise, the risk factors related to TDIs need to be identified comprehensively by all the possible ways to halt such injuries to occur.[5] So far, several risk factors for dental trauma have been reported in literature such as age, gender, geographical location, lip incompetency, and accentuated overjet, anteroposterior molar relation, overbite, ethnic group, socioeconomic status, obesity, peer relationships, family type, school grade, physical activity level, perception of paternal punishment, birth order, and psychosocial factors.[6],[7] These can be grouped into oral anatomical factors, environmental factors, and behavioral factors, etc.

Among orofacial anatomical risk factors, inadequate lip coverage and accentuated overjet have been studied extensively as a predictor for TDI, while overbite and molar relation have not been studied to that extent. Very few studies have investigated the association and strength of effect of all anatomical risk factors affecting TDI, and in most of them regression analysis method has been applied.

The multivariable analysis methods (i.e., multiple linear or logistic regressions statistics) have been used much for studying the associations of the variables. But, the limitations of them are the explanatory variables (covariates) occurrences when the clinical data are analyzed.[8] However, the concerns regarding the collinearity and multicollinearity which bring about forged results obtained due to multivariable statistical analysis have been overlooked in the dental research.[9] Science is all about for exploration of innovative tools.

Newer analysis techniques should be used to investigate the complex as[1]pects of risk factors of TDI. One such newer analysis method based on deep learning of artificial intelligence (AI) is the artificial neural network (ANN) that can be employed to perform nonlinear statistical modeling as new alternative to logistic regression.[10]

Initially, AI was supposed to be related to only robots or computers, but its applications are also found or evolved in the fields of medicine, dentistry, philosophy, linguistics, psychology, and statistics.[11]-[16] Various applications of AI in medical field have been reported such as: early detection of atrial fibrillation, blood glucose monitoring in diabetic patient, endoscopy and ultrasound for gastroenterology, seizure detection devices, diagnosis of cancer with computational histopathology, and imaging-based diagnosis.[12] In dentistry, AI has been reported in recent years for the early diagnosis of dental caries in bitewing radiograph[13]; for classification of the early childhood caries status in children[14]; for detection of dental plaque on deciduous teeth[15]; for the processing or application of zirconia crowns/restorations in dentistry[16]; for endodontic procedures such as locating apical foramen, prediction of periapical pathologies, retreatment predictions, analysis of root morphologies, and detection of vertical root fractures[17]; for the diagnosis in orthodontics specialty and its treatment planning; and in clinical decision-making process.[18]

Machine learning (ML), as a subfield of AI, provides imperative tools for intelligent data analysis.[19] The three main branches of ML have been developed: statistical methods, symbolic learning, and neural networks.[19] ANN algorithms are classified into: feed-forward neural networks (e.g., single-layer perceptron, MLP, and radial basis function networks) or recurrent neural networks (e.g., competitive network and Hopfield network).[20]

ANN have been found successful as a digital tool in solving highly complex problems of physical science by rapid data collection and processing.[21],[22] Its utilization is explicitly valuable in some conditions such as, when study data manifests complex interactions or when it does not satisfy the parametric assumptions, when the relationship between dependent and independent variables is not firm, when there is a large inexplicable variance in the information, or in circumstances of poorly understood theoretical basis.[21],[22]

Till now, no study has been published investigating the strength of influence of orofacial anatomical risk factors such as molar relationship, incisal overjet, overbite, and lip competency on the number of affected permanent teeth with TDI using deep learning algorithm of AI statistical methods. Therefore, the present study was done to analyze the influence of various anatomical risk factors such as overjet, overbite, molar relationship, and lip competency in determining the number of traumatized teeth per affected individual using the multilayer perceptron (MLP) model of ANN of deep learning algorithm of AI. This is the first study where all the possible anatomical risk factors together have been analyzed with the help of MLP model of AI. This article would be helpful for future researches in exploring the various other aspects of dental traumatology using the deep learning algorithm statistics of AI.

  Materials and Methods Top

The ethical approval for this study (D. N. 1030/FM) was provided by the Institutional Ethics Committee (IEC), Faculty of Medicine of Aligarh Muslim University, Uttar Pradesh, India on July 13, 2018. This was the cross-sectional study comprised of school-going-children aged 12 and 15 year selected randomly from ten schools from different locations of a city. The participating schools’ authorities were contacted and written informed consent was obtained after explaining the present study’s objectives and significances. Likewise, the informed consent was also obtained from the school children’s parents/caregivers. The sample size was determined by the following formula as:

(where, n = sample size; Z = z statistics for given level of confidence = 1.96 (for 95% Confidence Interval); p = expected prevalence = 39.5%; d = precision = 5.0%). After round off, the total sample size was calculated as 1000. The multistage cluster sampling technique was adopted for selecting the study population. A suitable schedule for conducting the study procedures in each school were discussed and finalized with schools’ authorities.

The age of participants was determined by seeing the children’s school identity card/school record or by observing the eruption status of dentition. The eligible participants were selected after considering the inclusion and exclusion criteria. Systemically healthy children without acute illness, willing children with consent from parents, aged between 12 and 15 year were included into the study. Children without informed consent, with acute illness, and undergoing/underwent orthodontic therapy made the exclusion criteria.

The intraexaminer reproducibility, accuracy, and consistency were assessed by kappa statistic and duplicate examination as per WHO guidelines (Oral health surveys-basic methods, WHO 2013).[23] The study data were collected by structured interview and dental examination using the self-prepared structured pro forma by the single investigator. Pro forma consisted of two sections where first section was for recording demographic data such as name, age, gender, school name, area, while second section comprised questions pertaining to dental trauma history, oral examination findings, risk factors (molar relationship, incisal overjet, overbite, and lip competency). Dental examination and structured interview of the study participants were performed in school hours within the school premises in relaxed environment where adequate illumination was available.

Strict infection control precautions were followed during entire study. Sterilized clean diagnostic instruments were used for dental examination. This study was carried out as per Declaration of Helsinki. TDI was recorded using Ellis and Davey classification. Ellis class VI fracture was not considered in study as no radiograph facility was feasible in the schools. Overjet was measured using the Community Periodontal Index of Treatment Needs (CPITN) probe as described by WHO.[24] Overbite was also measured using CPITN probe. Lip competence was assessed as described by Burden.[25]

The collected data were entered in Microsoft Excel sheet (version 2010). First descriptive analysis of all the dependent and independent variables was performed using SPSS software version 20. The association and strength of impact of orofacial anatomic risk factors were analyzed by MLP model of ANN of deep learning algorithm using the IBM SPSS Modeler software version-18 (IBM Corp., Armonk, N.Y., USA).

[Table 1] describes the MLP algorithm, where the “input layer” comprised of independent variables, that is, risk factors like molar relationship, incisal overjet, overbite, and lip competency). There was one “hidden layer.” The “output layer” consisted of dependent variables, that is, number of traumatized teeth with dental injuries. Hyperbolic tangent and softmax were chosen as the activation function for the hidden and output layer, respectively, in the MLP system.
Table 1 Description of neural network of multilayer perceptron (MLP) used during present study

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  Results Top

In this study, the total number of traumatized teeth was found as 164 in 135 affected children with TDI out of 1000 school children. [Table 2] depicts that majority of study participants with TDI had trauma in single tooth (80%) followed by two teeth (18.5%) and three teeth (1.5%). [Table 3] shows the frequency distribution of orofacial anatomical risk factors in study participants with TDI. Majority of affected children with dental injury had accentuated overjet (55.6%) as compared to normal overjet (<3.5 mm). Mostly, traumatized children with dental injuries had class-I molar relation (51.1%) followed by class-II division 1 (43.7%), class-II division 2 (4.4%), while class-III malocclusion showed minimum TDIs (0.7%). Majority of participants (51.1%) with TDIs showed reduced overbite as compared to accentuated overbite. Majority of affected children with TDI were found with competent lips (57%) as compared to incompetent lips (43%) [Table 3].
Table 2 Frequency distribution of number of traumatized teeth per subject

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Table 3 Distribution of anatomical risk factors in study participants with TDI

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[Table 1] and [Figure 1] depicting the input layers, hidden layers, and output layers of the MLP model where the estimated parameter indicating the predictors (input layers: molar relationship, incisal overjet, overbite, and lip competency) and predicted layers (hidden and output layer: number of traumatized teeth in with TDI). [Figure 1] demonstrating the nodes of all the layers connected by synaptic weight. [Table 4] and [Figure 2] showing strength of independent variables (risk factors) in the occurrence of TDI in number of teeth in terms of normalized importance. [Figure 2] shows that overbite (100%) was the strongest risk factor for the occurrence of TDI in number of teeth of affected participants followed by molar relationship (90.2%), overjet (87.7%), and the weakest risk factor was lip competency (57.2%).
Figure 1 Structure of the MLP neural network to predict the association and strength pattern of risk factors. The three-layered fully connected multilayer perceptron comprising of 10 input nodes, four hidden nodes, and three output nodes.

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Table 4 Prediction of strength of risk factors (independent variables) by MLP model in terms of normalized Importance

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Figure 2 Strength of orofacial anatomical risk factors in terms of normalized importance shown by MLP model of deep learning algorithm.

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  Discussion Top

In this research, anterior overbite (<3 mm), class-I molar relation, accentuated overjet (>3 mm), and competent lips were found in greatest frequency in affected children with TDIs.

In the present study, the strength of impact of oral risk factors (molar relation, overjet, lip competency, and overbite/openbite) on the causation of TDI in the number of teeth was analyzed using the MLP system, that is, a type of ANN technique of deep learning algorithm. To date, MLP method has not been used in any study analyzing the effect of risk factors in various parameters of TDI. The results of the present study described the complex associations of risk factors with the number of traumatized teeth in a quite simple and understanding way and hence, the overbite as an oral risk factor was found more strongly associated with the number of traumatized teeth with dental injury followed by molar relationship, incisal overjet, and lip competency.

The reason for getting more dental trauma with lowered overbite (<3 mm, open bite tendency) might be due to the lack of protective effect from the overlapping of maxillary anterior teeth with mandibular anterior teeth in occlusion. As the overbite increases more (deep bite tendency, >3.5 mm) there would be more protective effect from the vertical overlapping of anterior teeth (greater surface area will be covered). Overbite as a risk factor for TDI has been investigated in very few studies where increased overbite was contributing to TDI.[26]-[28]

The accentuated overjet was found in majority of participants with TDI. Hence, overjet makes the anterior teeth more vulnerable to dental trauma due to their protrusion. Similar findings have been reported by previous studies.[29] One study found no association among TDI, overbite, and overjet size.[30]

In the present study, the higher occurrence of TDI in children with Angle’s class-I molar relation may be because it is more common as compared to its counter parts. Class-1 malocclusion is more commonly found. In class-I type 2 malocclusion (Dewey’s modification, 1935), class-I molar relationship with proclined maxillary incisors (i.e., increased overjet) is found to be the reason of finding more TDI in such individuals.

Similar findings were reported in previous studies.[31],[32]

Kramer et al.[33] reported that molar relation had strong impact on TDI occurrence even after correcting the accentuated overjet and thus, demonstrated the independent impact of such class-1 malocclusion in anteroposterior direction.

Majority of TDIs were found in the participants with adequate lip coverage, and its possible reason might be the higher magnitude of impact of blow during traumatic incident dominates over the protective cushioning effect of soft tissue of lip coverage. Lip tissue get lacerated due to traumatic injury over orofacial region along with dental trauma which may be the possible reason of the present finding. Similarly, Traebert et al.[34] found no association between TDI and inadequate lip coverage.

The varying results of the studies might be due to the interplay among oral predisposing factors and behavioral factors and environmental factors for TDI.[35] Nguyen et al.[36] reported that age and gender are the confounding factors which influence the association between dental trauma and overjet. Thus, it seems that studies which do not adjust the confounders may show biased associations.

Mostly, studies have investigated the association among TDI, overjet, and lip coverage using regression analysis.[37]-[39] One study reported relation among TDIs, overjet, molar relation, and lip coverage using the Mantel–Haenszel common odds ratio method.[40] Very few studies evaluated the overbite as risk factor among other factors.[41]

In dental literature, age and gender have been the confounding factors for TDIs and have been mostly analyzed by conventional regression statistical models. Confounders are considered as extraneous variables that distort the apparent relationship between input (independent) and output (dependent) variables and hence lead to erroneous conclusions.

AI, especially ML, have evolved rapidly in respect of data analysis intelligently.[42] These ML methods make minimal assumptions regarding the data generating systems and they can be helpful even when the data are collected without a carefully controlled experimental design and also when the complicated nonlinear interactions are present.[43] It aids in the prediction of the patterns/relations in cumbersome data by employing general purpose learning algorithms. Generally, ANN model consists of three layers of neurons: input (receives information), hidden (responsible for extracting patterns, perform most of internal processing), and output (produces and presents final network outputs). Its processing units (nodes or neurons) are interconnected through synaptic weights that permit signals to travel via network.[44] Feed-forward networks are the common type of neural networks in medical applications.[20] These can be single layered (e.g., Adaptive Linear Neuron) or multilayered (e.g. MLP).[20]

The strength of the current study was the application of AI in the evaluation of impact of different anatomical risk factors on the number of teeth affected with TDIs in children and adolescents. Moreover, it provided the different perspective and valuable information with interpretation in simple ways about the interaction of various orofacial risk factors related to TDIs by employing the advanced neural network of deep learning algorithm of AI. As such, there are no limitations of the present study, yet relatively larger sample size and other age groups (e.g., young adults and older adults) could have been included. Hence, future researches related to dental traumatology using AI algorithm can include the larger sample size with other age groups.

  Conclusion Top

In the present study, by using the MLP model of deep learning algorithm of AI statistical method, overbite was found as the strongest anatomical risk factor in determining the number of traumatized teeth per affected individual as compared to molar relationship, overjet, and lip competence.

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  [Figure 1], [Figure 2]

  [Table 1], [Table 2], [Table 3], [Table 4]


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