Evaluation of the effects of malocclusion and orthodontic treatment on self-esteem in an adolescent population


The purpose of this study was to evaluate the effects of malocclusion and orthodontic treatment on adolescent self-esteem.


A total of 4509 middle school students were clinically evaluated for dental crowding. Lip protrusion was also measured with a specially designed ruler. Rosenberg’s self-esteem scale was used to determine each subject’s level of self-esteem.


The results showed that sex played a role in the relationship between self-esteem and malocclusion. For the girls, crowding of the anterior teeth had significant effects on their self-esteem; however, there was no significant difference in the boys’ self-esteem. After fixed orthodontic treatment, the girls had higher self-esteem than the untreated malocclusion group. Girls with an ideal profile and good tooth alignment also showed higher self-esteem than students with crowding or protrusion.


This clinical study proved that malocclusion and fixed orthodontic treatment can affect self-esteem in adolescent girls.

Orthodontic therapy is normally started for cosmetic considerations. Dentofacial problems causing cosmetic impairment are detrimental because of their adverse effect on an adolescent’s self-esteem and possible unfavorable social responses. The latter disadvantage might be in the form of blatant teasing and ridicule, particularly during childhood or more subtly as social bias. Such preconceptions are, of course, harmful if they become self-fulfilling prophecies.

Many factors related to malocclusion have strong influences on perceptions of facial esthetics, and many studies were done with various measurements and subjects. Recently mentioned factors are anterior tooth alignment, tooth shape and position, lip thickness, symmetric gingival or tooth contour, lip profile, overjet, and so on. Studies have proven that perceptions of facial esthetics influence psychological development from early childhood to adulthood. Infants show visual preference for human faces, and, by age 8, children’s criteria for attractiveness are the same as those of adults. A teacher’s perceptions of a student’s attractiveness can influence the teacher’s expectations and evaluation of the student.

Children perceived as more attractive are not only more socially accepted by their peers, but also believed to be more intelligent and to possess better social skills. In addition, employees perceived as more attractive by their supervisors are given better job-performance ratings than less attractive employees. Thus, those who are perceived by their teachers, peers, and employers to be attractive are more likely to experience positive social interactions and evaluations.

Although these relationships are well known and accepted, the direct relationship between self-esteem and malocclusion or orthodontic treatment has not yet been proven. Dann et al examined changes in self-concept during Class II treatment with an activator, showing a slight increase, but the changes after orthodontic treatment were found to be insignificant. O’Brien et al, however, verified that patients showed significant improvements in self-concept and self-esteem after Twin-block appliance therapy for the treatment of Class II Division 1 malocclusions.

The purpose in this study was to evaluate the influences of malocclusion and orthodontic treatment on adolescents’ self-esteem. To a layperson, anterior tooth alignment or protrusion would be the most conspicuous characteristics related to malocclusion; therefore, the effects of anterior crowding and lip protrusion on self-esteem were measured, and the influences of orthodontic treatment on self-esteem were also evaluated.

Material and methods

The sample consisted of adolescents aged 12 to 15 years from the first to third grades of 5 middle schools in Seoul, Korea. To control for the effects of socioeconomic status and location, we chose middle schools in Kang-nam Gu and Seo-cho Gu, which are in neighboring districts and represent middle to upper income groups. A total of 5343 middle school students were examined ( Table I ).

Table I
Subjects in this study
Total subjects examined Final sample
School Boys Girls Total Boys Girls Total
A 634 403 1037 602 323 925
B 614 452 1066 440 392 832
C 0 1042 1042 0 833 833
D 586 491 1077 523 408 931
E 0 1121 1121 0 988 988
1834 3509 5343 1565 2944 4509

Questionnaires designed to determine the students’ self-esteem were sent to the middle schools 1 week before the clinical examinations. They were then collected shortly before the examinations, so that the examiners would not know which students had high self-esteem.

Five orthodontists examined the subjects’ occlusal statuses and facial profiles. To minimize potential interexaminer differences, the methods of measurement and rules of grouping were explained, and sham clinical tests were performed before the examinations. To eliminate the effects of sex differences, statistical data from the boys and girls were analyzed separately.

To be included in the final study group, the samples had to satisfy all of the following criteria: (1) buccal segment (canines and premolars) eruption was completed; (2) there were no craniofacial anomalies, including cleft lip or palate; (3) all first molars were in place with no proximal caries or restorations; (4) there were no congenital missing teeth or impacted teeth mesial to the first molar; (5) and the questionnaire had been fully completed.

To assess the psychological influences of malocclusion and orthodontic treatment, Rosenberg’s self-esteem scale was used ( Fig 1 ). It has a Likert scale in which a positive or a negative response is weighed with a 4-point scale, ranging from “strongly agree” to “strongly disagree.” This scale was originally developed for and sampled on 5024 high school juniors and seniors from 10 randomly selected schools in New York state and has been used many times with proven reliability and validity for the general population and orthodontic patients ; it is simpler and more focused on self-esteem than other scales related to self-concept.

Fig 1
Rosenberg’s self-esteem scale.

The self-esteem questionnaire consisted of 10 questions; 5 were positive, and 5 were negative. For each negative statement, the answer was counted and added to the total score. For each positive statement, the answer was subtracted from 5, and then the remainder was added. In this study, self-esteem was evaluated based on the self-esteem index (SI). The SI was calculated by dividing the total score by 10. A subject with high self-esteem had a high SI score.

I classified the samples in 2 ways; the first classification was based on the profile and tooth alignment, and the second classification was based on the history of orthodontic treatment.

The most frequent reasons for seeking orthodontic treatment are protrusion and maxillary anterior crowding. Therefore, these conditions were evaluated ( Table II ), and we tried to measure their psychological influences. Protrusion at Ricketts’ E-line was measured clinically with a metal ruler with a 2-mm deep section removed at the middle ( Fig 2 ). If the upper and lower lips touched the middle of the ruler simultaneously (showing protrusion of more than 2 mm), the subject was classified in the protrusion group (PG).

Table II
Subjects grouped by types of malocclusion
Group Definition
CG Maxillary anterior (canine to canine) crowding >4 mm.
Upper and lower lip protrusion to E-line <2 mm on both lips.
No orthodontic treatment with fixed appliances.
PG Maxillary anterior (canine to canine) crowding <4 mm.
Upper and lower lip protrusion to E-line >2 mm on both lips.
No orthodontic treatment with fixed appliances.
CPG Maxillary anterior (canine to canine) crowding >4 mm.
Upper and lower lip protrusion to E-line >2 mm on both lips.
No orthodontic treatment with fixed appliances.
NG Class I molar relationship, crowding on both arches < 1 mm.
Good profile and no orthodontic treatment.
TR The rest of the subjects.

Fig 2
Evaluation of lip protrusion with the metal ruler.

Arch-length discrepancy in the maxillary anterior teeth was also evaluated. If more than 4 mm of arch-length discrepancy was suspected and the lips did not touch the ruler, the subject was classified in the crowding group (CG). Subjects who had both maxillary anterior crowding and lip protrusion were classified as the crowding and protrusion group (CPG). The normal group (NG) consisted of subjects with anterior crowding less than 1 mm, a Class I molar relationship, and a good profile. If these characteristics did not fit a subject or the clinical judgment was inconclusive, the student was put into the rest (TR) group. Molar relationship was a factor only in the NG. When classifying groups of malocclusion, whether the subject had prior experience with removable orthodontic appliances or headgear was not considered important. When the subject had prior experience with fixed orthodontic appliances, however, crowding and protrusion were not evaluated, and subjects were classified as the fixed orthodontic (FO) treatment group or the debonding group (finished fixed orthodontic treatment, DB).

All subjects were reclassified according to their histories of orthodontic treatment ( Table III ). The SI scores were compared among the FO, DB, removable orthodontic treatment (including headgear) (without fixed orthodontic treatment experience: RO), and no orthodontic (NO) treatment experience groups.

Table III
Subjects grouped by history of orthodontic treatment
Group Definition
DB Finished fixed orthodontic treatment (after debonding of fixed appliances)
FO During fixed orthodontic treatment
RO During or finished removable appliance (including headgear) orthodontic treatment
NO No orthodontic treatment

The SI scores of each group were compared by using 1-way analysis of variance (ANOVA) and the Scheffé multiple comparison. Boys and girls were compared separately.


Of the 5343 students examined from 2 all-girl schools and 3 coeducational schools, 4509 students who met the inclusion criteria were evaluated ( Table I ).

For the boys, the FO and DB groups included 13.48% (n = 211) and 9.07% (n = 142), respectively. The percentage of boys who had FO treatment (22.55%) was slightly less than that of the girls. The RO group constituted 5.43% of the sample (n = 85), and the NO group constituted 71.95% (n = 1126). The CG and PG groups were 6.52% (n = 79) and 4.29% (n = 52), respectively. Only 5 subjects (0.4%) had maxillary anterior crowding and lip protrusion simultaneously. The NG was 5.94% (n = 93) of the total sample, and TR group was 62.81% (n = 983).

For the girls, the FO group constituted 15.83% (466) and the DB group 10.73% (316); therefore, more than a quarter (26.56%) of the sample had FO treatment. Among the RO (n = 166) and NO (n = 1996) subjects, 8.05% (n = 174) showed maxillary anterior crowding (>4 mm; CG), and 4.17% (n = 90) exhibited lip protrusion that exceeded 2 mm (PG). Only 13 subjects had both maxillary anterior crowding and lip protrusion (CPG, 0.6%). The NG was 6.11% (n = 132) of the sample, and TR group was 59.54% (n = 1753).

Because there was no statistically significant difference between the SI scores of the girls in coeducational and all-girl schools, the findings were evaluated without school discrimination.

For the boys, their orthodontic treatment history made no difference in self-esteem levels; however, for the girls, self-esteem increased after FO treatment ( Table IV ).

Table IV
Comparison of self-esteem index (SI) scores of the groups
Boys Girls
Group n SI n SI
DB 143 2.89 ± 0.48A 316 2.86 ± 0.43A
FO 211 2.86 ± 0.46A 466 2.75 ± 0.42B
RO 85 2.76 ± 0.41A 166 2.75 ± 0.47B
NO 1126 2.80 ± 0.47A 1996 2.71 ± 0.45B
The same letters were not statistically significant at P = 0.05 with the Scheffé multiple comparison.

The CG, PG, and CPG exhibited lower SI scores, but without a significant difference in the male sample. For the female sample, the CG had a significantly decreased SI score, but the PG did not ( Table V ). There was no difference in the SI scores between the NG and the DB group based on sex.

Apr 14, 2017 | Posted by in Orthodontics | Comments Off on Evaluation of the effects of malocclusion and orthodontic treatment on self-esteem in an adolescent population
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