Relationship between normative and self-perceived criteria for orthodontic treatment need and satisfaction with esthetics and mastication in adolescents


Orthodontic treatments are performed to improve esthetics and masticatory functions. In general, clinical criteria are used to recommend such treatments without considering the opinion of the patient. This study aimed to evaluate the relationship between technically defined orthodontic need (normative criteria) and the need for treatment perceived by adolescent patients.


A total of 215 students aged between 15 and 19 years were selected and asked to respond to a questionnaire concerning their perception of need for orthodontic treatment and their satisfaction with their own esthetics and mastication. One trained and calibrated examiner obtained normative data using the Dental Aesthetic Index (DAI) on the need for orthodontic treatment of these students.


Associations were found between the DAI score and the patient’s perception of need for orthodontic treatment ( P <0.001), satisfaction with esthetics ( P = 0.003), and satisfaction with mastication ( P = 0.047). When occlusal characteristics were analyzed separately, associations between several normative and perceived needs, as well as for satisfaction with esthetics, were found . Satisfaction with mastication analysis was only found to be associated with open bite malocclusion ( P = 0.003).


The DAI revealed a consistent opinion in adolescents to link their perceived malocclusion-related conditions to esthetics.


  • Dental Aesthetic Index did not overestimate the need for orthodontic treatment.

  • Adolescents had sufficient insight to detect their malocclusions.

  • Social, economic, and demographic conditions were not associated with self-perception.

  • Malocclusions were more strongly related to esthetics than mastication.

Malocclusion, which is prevalent worldwide, affects a large percentage of the population. Apart from provoking changes in oral function, malocclusion can increase susceptibility to trauma, periodontal disease, and caries, and it can even cause biopsychosocial problems, which, in turn, affect quality of life. Furthermore, malocclusion may impact some individuals more significantly than other physical disorders, such as being overweight and obese.

Having well-aligned teeth has a strong influence on the perception of beauty, identification with professional success, and intelligence, and is associated with socially favored individuals. Conversely, patients with esthetic disorders may feel distressed and personally insecure. Perceived malocclusion can also be considered as a predictor of biopsychosocial impact and generally has a negative effect on individuals.

Occlusal indexes have been created to quantitatively determine the severity of malocclusion in a simple, quick, and precise manner, and to recommend those patients who have a greater need for orthodontic treatment. These occlusal indexes can normatively diagnose impairments at individual and collective levels. They can also be used for statistical analyses of epidemiologic studies. Most of the indexes used for the diagnosis and classification of malocclusion are based on clinical and/or epidemiologic criteria. Various occlusal indexes are available, including the Dental Aesthetic Index (DAI), which is an orthodontic index based on socially defined global esthetic norms.

Several studies have been performed using these normative indexes, but there are few that have investigated the association between malocclusion as defined by normative criteria and the self-perceived needs of the individual, as well as their satisfaction with esthetics and mastication. Instruments based exclusively on the normative criteria do not consider the individual opinions of the patients about their own health and/or esthetics, or even which type of malocclusion is perceived as a problem for them. This factor cannot be underestimated when the aim is to identify and measure an orthodontic problem that may or may not affect the life of an individual.

Owing to limited resources in the public service and the difficulty of diagnosing the severity of malocclusion correctly, the use of an instrument to objectively evaluate the needs and priorities of treatment in adolescents is necessary, but not sufficient. However, this need must be associated with the perceived needs of the patient; thus, combining their opinion about their satisfaction with esthetics and mastication with the normative criteria will bring greater benefit to those who really need orthodontic treatment. This study aimed to evaluate the relationship between technically defined orthodontic needs (normative criteria) and the treatment needs perceived by the adolescents enrolled in this study. The hypothesis was that orthodontic indexes overestimate the need for treatment in adolescents.

Material and methods

A sectional study was carried out with adolescents of both sexes aged between 15 and 19 years from the secondary, technical, and technological school of the Federal Institute of Education, Science and Technology, Natal-Central Campus, Brazil. The Federal Institute of Education, Science and Technology receives students from both the public and private educational systems in a heterogeneous way. A pilot study, with 30 students, which was a representative sample of 2826 adolescents, was previously performed to calculate the sample size, adopting a 5% level of significance.

Based on the results of the pilot study, 215 adolescents from the school were selected by convenience, following the same proportion of sex and age. Initially, the students were examined for the presence or absence of malocclusion. Then, a questionnaire ( Appendix ), in the form of a structured interview, was carried out, with questions about their perception of need for orthodontic treatment and satisfaction with their esthetics and mastication, as well as questions regarding their access to oral health services.

The clinical data, according to the DAI, was measured and recorded by a trained and calibrated examiner (kappa > 0.8). All data were recorded on an epidemiologic chart including the presence or not of any posterior crossbite.

The normative indexes were measured with a North Carolina periodontal probe, and the examinations were performed at the Institute’s dental clinic, where all biosafety standards were rigorously followed.

The questionnaires were answered in a suitable room, next to the dental clinic. First the questionnaire was fully explained to the students, who then answered all questions in writing without any external influence.

The protocol of this research study was sent to and approved by the Ethics Research Committee of the Federal University of Rio Grande do Norte, according to the norms of Resolution CNS/MS 196/96, and was registered under No. 489/2011.

To participate in the research, the parents of the participating students (if they were younger than 18 years) or the students themselves (if they were older than 18 years) completed and signed a Term of Free and Informed Consent.

After the clinical examinations and completion of the questionnaires, a descriptive analysis was conducted to compare the absolute and percentage frequencies for the categorical and measured variables and standard deviations for the quantitative variables using Stata 10.0 software (StataCorp, College Station, Tex).

Subsequently, a second analysis was conducted to evaluate the association between self-perception for treatment needs, the socioeconomic and demographic data, and access to the oral health service. In addition, the associations between self-perception for need for treatment, satisfaction with mastication and esthetics, and normative data were analyzed.

The chi-square test was used with continuity correction. The Fisher exact test was used when there was a cell with an expected value of <5. The prevalence ratio and its 95% confidence interval were also checked as a measure of magnitude of association. A significance level of 5% was used for all tests.


In relation to the socioeconomic and demographic variables, the data suggested a slight predominance of females (51.6%) over males (48.4%). The age distribution covered all age strata. Most adolescents (62.3%) had previously studied at a public school. Only 19.5% of the students did not live with their parents. Most parents (68.8%) had completed high school, and 66.4% of families received 2 or more minimum salaries. The sample represented both the rich and poor, with a predominance of middle-class families.

Data concerning the oral health services showed that only a small number of students had never visited a dentist. However, of the 210 students who had already visited a dentist, 94 (44.7%) reported that they did not make frequent preventive visits.

When seeking odontological services, most students went to a private dentist rather than the dentist’s office at the school or a public health clinic. Another relevant fact was the motivation of the last consultation. Esthetics, with regard to the positioning of the teeth, was the second most prominent reason to consult a dentist; this was second only to those who consulted a dental surgeon for a routine checkup. Orthodontic treatment was the third most common type of procedure among adolescents at their last visit to the dentist. This included students who were undergoing orthodontic treatment, and those who were having their first orthodontic consultation. However, a greater percentage than this was found for those undergoing routine dental procedures, such as cleaning with fluoride application and restoration and for esthetic reasons.

Clinical examination data, based on the DAI, showed that the prevalence of malocclusion was around 57.7%. The most frequent findings were irregularities in the mandible and molar relationships. There was an intermediate prevalence for crowding and spacing of the anterior region, followed by maxillary overjet and maxillary irregularities. Absence of dental elements and anterior crossbite were the least prevalent malocclusion-related conditions.

Although posterior crossbite is not present in the DAI, it was found in the clinical examination but with a low frequency of only 10.3%.

The DAI score showed that 31.5% of adolescents had a real need for treatment. However, according to their self-perception, most (68.9%) felt that they needed orthodontic treatment. Only 41.7% of students were satisfied with their esthetics; hence, there was a predominance of dissatisfaction or indifference with esthetics. On the other hand, 71.2% were satisfied with their ability to chew food.

The self-perception for need for treatment and satisfaction with esthetics by students who had already undergone orthodontic treatment produced an interesting (surprising) result. When these adolescents were asked about the need for treatment, a considerable portion (40%) answered yes; they thought they needed an orthodontic appliance, and only 32.1% were satisfied with their esthetics.

Table I shows the association between self-perception regarding the need for treatment, satisfaction with esthetics and mastication, and the socioeconomic and demographic variables and access to the oral health service. No significant association was found ( P >0.05) ( Table I ). This showed that socioeconomic and demographic factors and access to the oral health service are not associated with the opinions of adolescents related to dissatisfaction with esthetics and mastication, or their motivation to seek orthodontic treatment.

Table I
Relation between the socioeconomic demographic variables and access to the oral health service with self-perception need for orthodontic treatment, and satisfaction with esthetics and mastication
Variable Self-perceived need for orthodontic treatment Satisfaction with esthetics Satisfaction with mastication
Yes No P Value RP 95% CI Unsatisfied Indifferent Satisfied P Value Unsatisfied Indifferent Satisfied P Value
Age (y)
15-17 77 (68.1) 36 (31.9) 0.896 0.969 0.791-1.187 47 (37.6) 26 (20.8) 52 (41.6) 0.885 21 (16.7) 15 (11.9) 90 (71.4) 0.725
18-19 45 (70.3) 19 (29.7) 30 (34.9) 20 (23.3) 36 (41.9) 12 (14.0) 13 (15.1) 61 (70.9)
Boys 50 (61.7) 31 (38.3) 0.082 0.823 0.669-1.012 36 (35.6) 22 (21.8) 43 (42.6) 0.964 12 (11.7) 16 (15.5) 75 (72.8) 0.239
Girls 72 (75.0) 24 (25.0) 41 (37.3) 24 (21.8) 45 (40.9) 21 (19.3) 12 (11.0) 76 (69.7)
Previous school
Public 79 (70.5) 33 (29.5) 0.661 1.066 0.863-1.317 52 (39.4) 26 (19.7) 54 (40.9) 0.453 23 (17.3) 17 (12.8) 93 (69.9) 0.664
Private 43 (66.6) 22 (33.8) 25 (31.6) 20 (25.3) 34 (43.0) 10 (12.7) 11 (13.9) 58 (73.4)
Others 23 (74.2) 8 (25.8) 0.628 1.094 0.864-1.385 16 (38.1) 11 (26.2) 15 (35.7) 0.621 7 (16.7) 8 (19.0) 27 (64.3) 0.417
With parents 99 (67.8) 47 (32.2) 61 (36.1) 35 (20.7) 73 (43.2) 26 (15.3) 20 (11.8) 124 (72.9)
Educational level of mother or head of family
Elementary school complete or incomplete 41 (74.5) 14 (25.5) 0.634 1.18 0.868-1.440 28 (44.4) 14 (22.2) 21 (33.3) 0.306 11 (17.2) 7 (10.9) 46 (71.9) 0.922
High school 49 (68.1) 23 (31.9) 1.021 0.791-1.317 31 (35.2) 21 (23.9) 36 (40.9) 12 (13.6) 12 (13.6) 64 (72.7)
Technical school or college degree 32 (66.7) 16 (33.3) 1 16 (28.6) 11 (19.6) 29 (51.8) 10 (17.9) 8 (14.3) 38 (67.9)
Monthly income
A, B 26 (72.2) 10 (27.8) 1 31 (45.6) 11 (16.2) 26 (38.2) 8 (19.0) 6 (14.3) 28 (66.7)
C 49 (63.6) 28 (36.4) 0.881 0.677-1.147 30 (31.6) 24 (25.3) 41 (43.2) 10 (10.5) 11 (11.6) 74 (77.9)
D, E 41 (70.7) 17 (29.3) 0.561 0.979 0.753-1.272 31 (45.6) 11 (16.2) 26 (38.2) 0.316 14 (20.6) 9 (13.2) 45 (66.2) 0.391
Dentistry service
Public 42 (68.9) 19 (31.1) 0.976 0.978 0.791-1.209 33 (42.3) 14 (17.9) 31 (39.7) 0.635 17 (22.1) 12 (15.6) 48 (62.3) 0.211
Private 69 (70.4) 29 (29.6) 41 (36.0) 25 (21.9) 48 (42.1) 15 (13.0) 16 (13.9) 84 (73.0)
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Jan 7, 2020 | Posted by in Orthodontics | Comments Off on Relationship between normative and self-perceived criteria for orthodontic treatment need and satisfaction with esthetics and mastication in adolescents
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