Introduction
The face is arguably the most pivotal aspect of an individual’s physical appearance. Since times immemorial, we have been fascinated by beautiful faces. Aesthetics apart, ‘the face’ imparts a unique character and identity to an individual. A pleasing personality has been linked to a beautiful face, influencing our developmental process.
Indeed, a primary incentive for seeking orthodontic treatment is to improve both dental and facial aesthetics, besides improving function and oral health status.
A balanced face is the outcome of intricate proportion and balance between the hard tissues, that is, the craniofacial skeleton, dentoalveolar structures and their soft tissue drape around it, in function and at rest. A dental and/or skeletal malocclusion may upset this balance and hence may lead to dissatisfaction with life in an individual. The deformities of the mouth and the face, which comprise the communicative zone, affect an individual’s self-esteem more adversely. Therefore, aesthetics comprises not only the face but also the teeth, the jaws and the occlusion.
Psychological implications of malocclusion
The adverse effects of poor facial aesthetics, motivating a person to seek orthodontic treatment can be broadly divided into:
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Low self-esteem and maladjustment
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Quality of life (QoL) and psychological stress
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Restriction of social activities
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Adverse occupational outcomes.
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Low self-esteem and maladjustment : The motivation to seek orthodontic treatment is strongly related to an individual’s perception of the extent to which his dentofacial appearance deviates from the social norm. Psychosocial handicaps imposed by an un-aesthetic dental appearance may have a negative impact on the personality of a child who may be often subjected to ridicule in the form of teasing, name-calling and sometimes even mobbing by peers. This mental anguish imposed in early life may evoke feelings of inadequacy in the child which may well sustain for life, leading to a maladjusted individual.
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Quality of life and psychological stress : Malocclusion symptoms and their severity also affect an individual’s QoL and may considerably contribute to psychological stress and anxiety. Psychosocial impact increases with the severity of malocclusion and may influence an individual’s self-confidence and social life. A study reported lower disease-specific QoL in patients with a non-surgical malocclusion correction. Some studies have found a significant reduction in depressive symptoms and improvement in disease-specific oral health–related QoL and anxiety after surgery. ,
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Restriction of social activities : Those perceived as attractive are believed to have heightened social charm and appeal, thereby influencing how social characteristics are perceived:
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Perceived friendliness
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Popularity among peers
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Academic performance
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Adverse occupational outcomes : Malocclusion can pose a significant social challenge, making it challenging for the affected individual to smile, speak in public or engage with others. Facial appearance may also influence job opportunities, with attractive faces often having an advantage over less attractive ones. Consequently, malocclusion is closely linked to an individual’s social performance and overall well-being.
Psychological factors motivating patients to seek orthodontic treatment
Motivation, according to the social cognitive theory, is a dynamic and reciprocal interaction of a triad of three factors :
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Personal factors
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Behavioural factors
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Environment factors
Not all of these factors interact equally. For some, social influences and environment predominate, whereas, for others, personal experiences, feelings and personality traits may play a major role. The sequence and magnitude by which these factors impact an individual’s motivation and expectations from orthodontic treatment are determined by the following:
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Age
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Gender
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Socio-economic set-up
However, the extent of psychological distress does not exhibit a direct correlation with the severity of the dentofacial anomaly. Consequently, one person may develop a more negative body image due to a slight deviation, such as a rotated lateral incisor or a median diastema, compared to another person experiencing a more pronounced anomaly of occlusion or facial deformity.
Motivating factors vary among different age groups. What is paramount for a teenager may be less significant for an adult seeking orthodontic treatment. Teenagers find it difficult to avoid the norms and values of their desired reference group. Their social environment strongly influences these norms, including the media portrayal of an ideal body image.
The inclination towards attractiveness is progressively ingrained under the influence of the following factors ( Fig. 9.1 ).
The inclination towards attractiveness is progressively ingrained under the influence of the following factors.
Type and severity of malocclusion
It is one of the primary reasons for seeking orthodontic treatment, particularly ‘large overjet’ or protruding or severely irregular teeth. Children with significant malocclusion are more inclined to seek orthodontic treatment (keeping the other governing factors like socio-economic status, affordability, availability of services and parents’ attitudes in common) than children with a mild irregularity of teeth.
The other factors that may influence the need for treatment are social class, awareness and concern. Anterior or forwardly placed teeth are the usual cause of teasing in school and may generate concern and reason for orthodontic treatment. In a study done in Finland, parents of 473 children were screened for their child’s dental/facial appearance, reasons for seeking orthodontic treatment and the referral paths. Nearly all (85%) of the 313 parents of children below 16 years expressed worry regarding their child’s teeth, of which 44% of parents stated that their child had experienced teasing at school. The recognition of the need for treatment was initiated by the child, with overjet and malalignment of teeth being the primary reasons for teasing.
Another study used the Dental Health Component (DHC) of the Index for Orthodontic Treatment Need (IOTN) to evaluate the prevalence of malocclusion and the need for orthodontic treatment in children between 10 and 15 years. The findings of the study showed that orthodontic treatment is required for missing teeth (13.2%), correction of overjet (11.9%), correction of crossbite (13.2%), correction in displacement of contact point (29%) and correction in overbite (15.8%).
Self-perception of malocclusion
The concern for a deviation or a trait of malocclusion does not directly correlate with the severity of the problem. A child might experience concern and anxiety over a slight tooth deviation, whereas others might be indifferent to more noticeable irregularities. Such perception and concern would be dependent, to a large extent, on parents’ perception of malocclusion, which may get transferred to a child or else a child may develop his/her concerns, which to some extent may be linked with awareness and education, besides child’s personality and priority for well-being and self-image. However, gender, age, self-esteem, education and socio-economic condition may affect child’s self-perception about his/her dental appearance and orthodontic treatment.
In a study involving British children requiring orthodontic treatment, Gosney (1986), observed that some children were either unaware or unconcerned about a noticeable malocclusion, while others exhibited notable concern over a relatively mild irregularity.
The concept of self-image and concern for the deformity may vary and change with age. Many adolescents may describe themselves as not good looking or strange. Moreover, if they frequently exposed to negative social experiences, they describe themselves and their characteristics as abnormal. A recent study has assessed self-perception of dental aesthetics and malocclusion among 13–15-year-old Indian schoolchildren and found higher self-perception and concern about dental aesthetics on oral aesthetic subjective impact scale (OASIS). However, many children may not seek orthodontic treatment during childhood but instead seek treatment in adulthood and become aware of its need for social or functional reasons.
Parental perception of malocclusion
Parents have a significant role in initiating treatment and supporting compliance with the child’s orthodontic treatment. Most often, it was parents who first identified their children’s irregular teeth. It was noticed that mothers’ perception affects children’s perception of orthodontic treatment needs and satisfaction with the appearance of his/her teeth. Baldwin and Barnes , noted that the mother plays a crucial role in mobilizing, deciding and determining the decision for orthodontic treatment. They noted that in such cases, the mother typically came from a more affluent socio-economic background than her husband and might have faced orthodontic challenges in the past. It has been observed that the father tended to have a less active role in the decision-making process for orthodontic treatment. When the father was the primary decision-maker, it was typically for the daughter’s treatment. The following factors among parents were identified as responsible for seeking orthodontic treatment for children.
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Parents try to address issues with their self-concepts by identifying with the child and their treatment.
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Feelings of guilt may arise concerning their hereditary deformity among either of the parents.
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The perception of orthodontic treatment as a symbol of social status.
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It has been noted that children residing with a divorced mother, often grappling with psychological challenges, are often provided orthodontic treatment as a kind of ‘psychic gift’ to compensate for the absence of a father.
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They try to address an unsolvable family health issue by redirecting it onto the child’s orthodontic problem and treatment.
These factors would mean that the child may withdraw or have little motivation for treatment. He/she may withdraw from participation in the decision to seek treatment. If this occurs in a child with a minor malocclusion, the child may have no incentive for cooperation during treatment and may turn uncooperative. Given the above factors, it is wise for the dentist/orthodontist to know about the patient’s attitude towards treatment and ensure that the patient becomes an active participant in the treatment team comprising the patient, the parent and the orthodontist. An uncooperative patient attitude can lead to several problems during treatment, unsuccessful treatment results or poor outcomes.
Gender
Despite an equal prevalence of malocclusion among males and females, a larger proportion of girls seem to seek orthodontic treatment compared to boys. This is the reflection of the so-called ‘sex stereotyping’ wherein society places greater emphasis on and has higher expectations for physical attractiveness in females compared to males. Additionally, it has been observed that females tend to be more critical of their dental appearance and dissatisfied with the appearance of their dentition than males. , Bergman and Eliasi examined the psychological impacts of malocclusion, attitudes and opinions of orthodontic treatment in population groups from Singapore and Sweden ( Fig. 9.2 A,B). A notable finding was that females and males perceive facial aesthetic features differently. The complexion was more critical for facial aesthetics according to males and females in Singapore and only the male in Stockholm populations. However, according to Stockholm’s female population, face shape is essential for facial aesthetics. Females are more concerned about their dental defects than males, and the concern is more likely among individuals belonging to the higher socio-economic class.
(A and B) Reasons of seeking orthodontic treatment do vary with ethnic and social factors.
Source: Based on the data and concept of Bergman L, Eliasi F. Sociocultural influence on attitudes about orthodontic treatment and treatment need, Institute of Odontology, Karolinska Institute, and Huddinge, Sweden. http://www.ki.se/odont/cariologiendodonti/978/Lisbeth Bergman Farah Eliasi.pdf page 215-44.
Peer pressure
Adolescents with ideal smiles may be considered popular, great leaders, intelligent and healthier. Consequently, adolescents with malocclusion wants acceptance and popularity in their peer group. They may show negative behaviours and live an isolated social life when they experience frequent rejection from their peers. A study has found that females received more comments from their relatives or friends and were also bullied or harassed at school due to their teeth than males. Hence, peer pressure is one of the reasons for seeking dental advice.
It has been well found that many school children may seek advice on the need for ‘braces’ like their peers. Some students may consider it exciting, while others may consider wearing ‘braces’ an embarrassment. There are differences in perception of wearing ‘braces’ in the school population and referred population for orthodontic treatment. There might be a widespread issue regarding the acceptance of ‘braces’ in a particular population class, while in another, it might be regarded as a ‘badge of honour’. Familiarity with the appliance may reduce resistance to wearing the appliance. However, communication among peers, difficulties with chewing food, pain due to appliance breakages, difficulties in speaking and extra effort in the maintenance of oral hygiene and extraction of a tooth (teeth) may discourage others from undergoing orthodontic treatment.
Shaw et al. suggested, and it has been the author’s clinical observation, too, that exposure to the sight of an appliance may trigger an interest in seeking similar ‘objects’ or treatment.
The studies on patients’ perception of orthodontic treatment needs and professional assessment of orthodontic treatment needs do vary. Some studies have IOTN as a professional ruler to assess the need and patients/parents questionnaires on subjective need. The IOTN has two components: the DHC and the aesthetic component (AC). The DHC must be assessed by a calibrated professional for IOTN. Anterior spacing, anterior open bite, increased overjet and crowding may negatively affect adolescents’ social acceptance. A study by Shue-Te et al., conducted at various orthodontic offices in San Francisco, California, USA on patients and their pre-treatment study models, confirmed that A) was the significant motivating factor for seeking orthodontic treatment.
Body image and self-esteem
Dentofacial deformities can give rise to emotional distress, ranging from embarrassment to mental anguish. It is essential to contemplate the concept of body image for a deeper insight into this somatopsychic factor.
Individuals construct a conscious representation of their appearance, usually striving for a positive one. In cases where this self-image falls short of satisfaction, it can trigger anxiety, and if left unresolved, it may lead to mental health issues. Two aspects need consideration concerning dentofacial defects. The first aspect involves the individual’s attitude towards their body—an attitude shaped by their response to the defect and their perception of others’ reactions. A child subjected to teasing about his/her defect is likely to develop a body image distinct from that of a child without a dentofacial defect. The second aspect concerns how others respond to the disability, encompassing the extent to which one’s relationships are affected by others’ varied responses to the defect for example, lack of acceptance and/or reactions ranging from mild amusement to horror. An individual’s body image often diverges from an objective representation of the body, and the severity of disfigurement does not necessarily have a direct proportional relationship to the anxiety it induces. Roots , stated that the predominant psychological consequence of dentofacial deformity is the development of an inferiority complex.
The sense of inferiority is a complex, painful emotional state characterized by feelings of incompetence, inadequacy and depression in varying degrees. Feelings of inferiority depend on an individual’s comparison of himself with others. The impact of this inferiority complex becomes significant once the child starts attending school. At that point, the child becomes aware of his/her distinctions from others and discovers challenges in enjoying the company of his/her peers. As the individual enters adolescence, a sense of despair and a pessimistic life philosophy, combined with various unique personal traits, may have been established. Secord and Backman conducted a study to ascertain whether specific dentofacial characteristics associated with physical attractiveness elicited consistent stereotypical judgments about the individual. They examined the protrusion of the maxillary teeth, protrusion-recession of the chin and alignment of the teeth. Their study showed that certain personality traits became stereotyped based on an individual’s dentofacial appearance. It has also been observed that children with malocclusion frequently experience a lack of affection and attention from their parents, potentially resulting in feelings of frustration and depression that may contribute to introverted tendencies.
Furthermore, studies have shown that the primary psychological consequences of malocclusion are influenced not only by how others respond to the dentofacial irregularity but also by the individual’s reaction to the deformity and how they value and appreciate themselves. Adolescents with malocclusions aged between 14 and 15 years may show the most minor self-esteem as compared to adults (≥18 years old). , Multiple malocclusions and female gender are negativity associated with lower self-esteem and may lead to psychological, social and physical discomfort to them. However, after orthodontic treatment, individuals may report a low level of aesthetic concern and a high level of self-esteem as compared to orthodontically untreated patients.
Patient’s personality traits
Personality traits can also be considered motivational factors affecting cooperation during orthodontic treatment. The doctor–patient relationships may be affected by individuals’ problems with social adaptation, mental health and personality deficits. A study used the Eysenck Personality Questionnaire (EPQ) to evaluate adult patients’ personality and psychosocial status before the orthodontic treatment. The study findings showed that these patients are introverted and pessimistic (lower score on extroversion/introversion scale) and likely to have anxiety, tension and depression (high scores on neuroticism scale). At the same time, some patients may show hostility and lack of compassion (high score on psychoticism).
The traits of cooperative and uncooperative orthodontic patients are summarized in Table 9.1 .
TABLE 9.1
Psychological factors and personality traits affecting cooperation during orthodontic treatment
| A cooperative patient | An uncooperative patient |
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| Psychosocial factors | |
| It could be related to their greater concern about problems/aesthetics | Those children who have a poor relationship with parents at home and with teachers and peers at school |
| Treatment has been initiated by the child himself and decided by the parents with child being taken into confidence | The parents have decided treatment without child being taken into confidence |
| Children with excellent family rapport | Children from broken families |
| Personality traits | |
| Usually around 14 years or younger | Usually around 14 years or above with superior intelligence |
| Enthusiastic | High headed |
| Outgoing | Independent |
| Energetic | Aloof |
| Self-controlled | Temperamental |
| Responsible | Impatient |
| Determined | Often nervous |
| Trusting | Individualistic |
| Determined to do well | Self-sufficient |
| Forthright | Intolerant |
| Obliging | Disregards wishes of others where his decisions are involved |
| Hard working | Easy going |
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