Introduction
This article evaluates and reports on the satisfaction of adult patients across the United States who received orthodontic treatment for anterior open bite malocclusion. The factors that influence satisfaction are also described.
Methods
Practitioners were recruited from the National Dental Practice-Based Research Network. On joining the Network, practitioner demographics and information on their practices were acquired. Practitioners enrolled their adult patients in active treatment for anterior open bite. Patient demographics, patient dentofacial characteristics, and details regarding previous and current treatment were collected through questionnaires at enrollment (T1). Pretreatment lateral cephalograms and intraoral frontal photographs were submitted. Treatment performed, and details related to treatment outcome were recorded through questionnaires at the end of active treatment (T2). Posttreatment lateral cephalograms and intraoral frontal photographs were submitted. Patient satisfaction at T2 was assessed using a 5-point Likert-type scale and open-ended responses. Predictive univariate models were developed to evaluate the factors that affect patient satisfaction. Open-ended responses were reviewed for general trends.
Results
T2 data were received for 260 patients, and 248 of these patients completed and returned the patient satisfaction questionnaires. High levels of satisfaction were found in this sample of adult patients receiving treatment for anterior open bite malocclusion. Specifically, 96% of the sample reported being very or somewhat satisfied. Only 10 patients (4%) were not satisfied with the treatment provided or an element of the final result. Successful open bite closure, treatment modality, and certain patient characteristics may affect patient satisfaction. However, there was insufficient power to demonstrate statistical significance because of the very low number of dissatisfied patients. Open-ended responses directly associated with patient satisfaction were received from 23 patients (9%). They relayed positive, neutral, and negative feelings about the treatment received and final results. Additional responses regarding the orthodontic treatment in general, but not specifically linked to patient satisfaction, were received from 119 patients (48%). These comments depict an overwhelmingly positive experience.
Conclusions
Adult patients who received orthodontic treatment for anterior open bite malocclusion were generally satisfied with the treatment provided, as well as the final esthetic and functional results.
Highlights
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Patient satisfaction associated with the treatment of anterior open bite malocclusion was evaluated.
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High satisfaction levels were observed at the end of active treatment.
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Treatment success, modality, and patient characteristics may affect satisfaction.
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Open-ended responses depict an overwhelmingly positive experience.
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The value of a positive patient-provider relationship was demonstrated.
Anterior open bite (AOB) was first described in the dental literature more than 150 years ago. It can be defined as a lack of vertical contact and overlap of the anterior teeth in maximum intercuspation. The prevalence of AOB in the United States ranges from 0.6% to 16.5%, depending on age and race. The etiology of AOB is complex and multifactorial. Oral habits, unfavorable growth patterns, respiratory factors, and neuromuscular imbalance have been suggested to play a role. AOB often results in significant esthetic and functional concerns, including difficulty incising food and speaking. , ,
AOB is widely considered to be one of the most challenging malocclusions to treat. Although numerous strategies have been proposed to treat patients with AOB, there is no consensus as to which is the preferred treatment modality for a particular case. Current evidence on the success of AOB treatment is based primarily on retrospective case series. This literature only evaluates clinical outcomes. Patient satisfaction associated with the treatment of AOB malocclusion has not been evaluated.
Over the past few decades, the health care literature has placed an increased emphasis on quality of life. Improvement in quality of life is a fundamental goal of medicine and dentistry. Orthodontic treatment, specifically, aims to enhance oral health–related quality of life through the correction of malocclusion, , as well as improvement of dentofacial esthetics and oral function. Therefore, it is important for the orthodontic literature to evaluate patient-centered outcomes. Traditional orthodontic outcome measures do not necessarily reflect patient values and, until recently, patient perspectives have received limited attention in the orthodontic literature. , , In this report, we investigate the satisfaction levels of adult patients after receiving orthodontic treatment for AOB malocclusion. We also describe the factors that are associated with satisfaction and dissatisfaction.
In 2015, the National Dental Practice-Based Research Network (PBRN) Adult Anterior Open Bite Study was launched. The purpose of this large observational prospective cohort study was to explore treatment recommendations, outcomes, stability, and satisfaction of adult patients with AOB. The study was divided into 3 phases: enrollment (T1), end of active treatment (T2), and 1-year posttreatment (T3). A prior publication characterizes the practitioners and patients enrolled in the study. Another previous publication details the factors that influence treatment recommendations. This paper describes patient satisfaction at T2. A concomitant publication addresses treatment success at T2. A subsequent publication will describe treatment success and patient satisfaction at T3.
Material and methods
Providers were recruited from the National Dental PBRN, comprised of 6 geographic regions: West, Midwest, Southwest, South Central, South Atlantic, and Northeast. Institutional review board (IRB) approval for this study was obtained from several institutions, representing the regions of the Network. These included the University of Alabama at Birmingham IRB acting as the central IRB, the Kaiser Permanente Northwest IRB for the Western region, and the University of Rochester Research Subjects Review Board for the Northeast region. In addition, IRB approval was obtained at individual academic settings when required.
The inclusion criteria for practitioners were as follows: (1) orthodontist or dentist that routinely performs orthodontic treatment, (2) estimates to recruit 3-8 adult patients in active treatment for AOB and expects to complete treatment within 24 months of enrollment into the study, (3) routinely takes cephalometric radiographs before and after treatment, (4) able to upload deidentified cephalometric radiographs and digital intraoral frontal photographs to a central data repository, (5) affirms that the practice can devote sufficient time in patient scheduling to allow recording of the required data, and (6) does not anticipate retiring, selling the practice, or moving during the study.
The inclusion criteria for patients were as follows: (1) at least 18 years of age at the time of enrollment; (2) must have AOB, which is defined as at least 1 incisor that does not have vertical overlap with teeth in the opposing arch. The remaining incisors may have minimal incisor overlap but cannot contact teeth in the opposing arch. This will be determined by examining the patient’s initial cephalometric radiograph, intraoral photographs, and/or initial plaster or digital casts; (3) must be in active treatment for AOB and expects to have treatment completed within 24 months of enrollment in the study; and (4) must have an initial cephalometric radiograph (taken before the beginning of treatment). A cephalometric radiograph created from a cone-beam computed tomography scan is acceptable.
The exclusion criteria for patients were as follows: (1) clefts, craniofacial conditions, or syndromes; (2) significant physical, mental, or medical conditions that would affect treatment compliance, cooperation, or outcome; (3) expects to move before the completion of the study; and (4) initial treatment plans estimated to be >36 months.
Recruitment was restricted to patients ≥18 years of age to minimize, although not eliminate, the influence of facial growth on treatment outcome. To avoid selection bias, practitioners were requested to enroll all eligible patients. A maximum of 15 patients per practitioner was established. If a practitioner had >15 eligible patients, the patients were selected sequentially on the basis of their treatment start dates.
On joining the Network, practitioner demographics and information on their practices were acquired. Patient demographics, patient dentofacial characteristics, and details regarding previous and current treatment were collected through questionnaires at T1. Changes to treatment (ie, added or removed procedures) and details related to treatment outcome were recorded through questionnaires at T2. Patient satisfaction was assessed using a 5-point Likert-type scale and open-ended responses at T2. Patients placed completed satisfaction evaluations in sealed envelopes. Questionnaires were sent to regional centers, where they were reviewed for completeness and entered into a centralized database. More details on data collection from practitioners and patients can be found in a previously published paper. Study forms can be accessed at https://www.nationaldentalpbrn.org/study-results/#1589299528044-b9cab599-914e . Intraoral frontal photographs were taken parallel to the occlusal plane. Practitioners were provided with sample photographs, demonstrating correct and incorrect vertical orientation.
Pre- and posttreatment lateral cephalograms and intraoral frontal photographs were uploaded to a centralized, Web-based system. Deidentified images were forwarded to the research team at the University of Washington. The radiographs were imported into Dolphin Imaging software (version 11.0; Dolphin Imaging and Management Solutions, Chatsworth, Calif), landmarks were identified by 2 examiners (S.A.F. and L.S.T.), and an automated, custom cephalometric analysis was performed on the basis of the selected landmarks. A depiction of the cephalometric landmarks can be found in a previously published article. Cephalometric landmarks were first identified by one examiner and then reviewed by the other examiner. Disagreements in landmark identification were resolved by means of consensus between the examiners.
A standard millimetric ruler in the lateral cephalogram was used to calibrate millimetric measurements. If a ruler was present in a patient’s pretreatment lateral cephalogram, but absent in the posttreatment lateral cephalogram, the sella-nasion distance of the pretreatment lateral cephalogram, measured using the ruler, was used to calibrate the posttreatment lateral cephalogram. The same process was followed, in reverse, if a ruler was present in a patient’s posttreatment lateral cephalogram, but absent in the pretreatment lateral cephalogram. If a ruler was absent on both a patient’s pre- and posttreatment lateral cephalograms, an average nasion-menton distance was used to calibrate the pretreatment lateral cephalogram. , The posttreatment lateral cephalogram was then calibrated using the sella-nasion distance of the pretreatment lateral cephalogram, as described above. This surrogate calibration method was validated by sensitivity analysis.
An index was developed to score the relative open bite severity using the intraoral frontal photographs. The Photographic Open Bite Severity Index (POSI) has 7 categories, defined by the type and number of teeth that do not have vertical overlap ( Fig 1 ): (0) all 4 incisors with vertical overlap; (1) 1 or 2 maxillary lateral incisors without vertical overlap (both maxillary central incisors have vertical overlap); (2) 1 maxillary central incisor without vertical overlap (the other maxillary central incisor has vertical overlap); (3) both maxillary central incisors without vertical overlap (at least 1 maxillary lateral incisor has vertical overlap); (4) all 4 maxillary incisors without vertical overlap; (5) all anterior teeth, including canines, without vertical overlap; and (6) all anterior teeth and at least 1 premolar, without vertical overlap.
The intraoral frontal photographs were rated independently by the same 2 examiners (S.A.F. and L.S.T.). Disagreements in POSI scores were resolved by means of consensus between the examiners.
Both examiners underwent training and calibration before landmarking lateral cephalograms and assessing intraoral frontal photographs. Ten lateral cephalograms and 20 intraoral frontal photographs were randomly selected to determine inter- and intrarater reliability. The lateral cephalograms and intraoral frontal photographs were analyzed twice, 1 month apart, by both examiners. Inter- and intraexaminer reliability was assessed with an intraclass correlation coefficient. All values were >0.90, indicating that landmark identification and POSI classification were reliable by each examiner over time, as well as between examiners.
Statistical analysis
Patient satisfaction at T2 was assessed using a 5-point Likert-type scale: very satisfied , somewhat satisfied , neither satisfied nor dissatisfied , somewhat dissatisfied , and very dissatisfied . Patients were asked to provide explanations after answers of somewhat or very dissatisfied . Satisfaction with the orthodontic treatment provided, satisfaction with esthetics, and satisfaction with function were evaluated separately. Whether or not treatment would be recommended to a friend with a similar malocclusion was also evaluated using a 5-point Likert-type scale: definitely recommend , probably recommend , undecided , probably not recommend , and definitely not recommend . Patients were asked to provide explanations after answers of probably or definitely not recommend .
Satisfaction rates were calculated by grouping responses: satisfied ( very satisfied and somewhat satisfied ) vs not satisfied ( neither satisfied nor dissatisfied , somewhat dissatisfied , and very dissatisfied ). Whether or not treatment would be recommended to a friend can be considered a proxy for patient satisfaction with the orthodontic treatment provided. The likelihood of this recommendation was also quantified by grouping responses: would recommend ( definitely recommend and probably recommend ) vs would not recommend ( undecided , probably not recommend , and definitely not recommend ). Open-ended responses were reviewed for general trends.
Several measures were used to evaluate treatment success. Patient-perceived treatment success was determined at T2 by asking patients if their open bite was successfully closed. Practitioner-reported treatment success was determined at T2 by asking practitioners if the open bite was successfully closed. Lateral cephalometric radiographs were used to evaluate treatment success, defined by positive overbite at T2. Specifically, posttreatment lateral cephalograms were analyzed to determine if positive incisor overlap was achieved. Finally, the POSI was used to evaluate treatment success, defined as a score of 0 at T2.
Success can be defined by the 4 measures described above. Patient-perceived and practitioner-reported treatment successes are subjective. Treatment success defined by the cephalometric analysis only uses the most anterior maxillary and mandibular central incisors to calculate overbite and therefore may not account for the vertical overlap of the other incisors. In contrast, the POSI scores the vertical overlap of all 4 incisors in maximum intercuspation. Preliminary analyses indicated that the POSI is the most discriminating measure to assess successful open bite closure ( Supplementary Table I ).
Four treatment modalities were recognized: (1) aligners without fixed appliances, temporary anchorage devices (TADs), or orthognathic surgery (SX); (2) fixed appliances without TADs or SX, (3) TADs without SX; and (4) SX. These categories represent an increasing ability to manage more complex malocclusions, as well as an increasing level of invasiveness. Patients treated with a combination of appliances were placed in the higher treatment category. For example, a patient treated with aligners and fixed appliances would be placed in the second treatment category. The effect of extractions on patient satisfaction was also explored.
Treatment duration was calculated as the time from appliance placement to appliance removal, on the basis of information from T1 and T2 questionnaires, respectively.
Information about the age, sex, race, insurance coverage, education level, and previous orthodontic treatment of the patients was collected.
Information about the age, sex, race, years in practice, geographic region of practice, and practice type of the practitioners was collected.
Univariate analyses of continuous variables (means, standard deviations [SD], and ranges) are presented. Bivariate analyses were used to evaluate the effect of the previously mentioned predictors on patient satisfaction. Statistical significance was adjusted for the clustering of patients within practitioners using generalized estimating equations. Statistics were processed using PROC GENMOD in SAS with CORR = EXCH option. However, because of the very small number of dissatisfied patients, most comparisons were not estimable statistically. Thus, with few exceptions, only descriptive frequencies of the bivariate analyses related to satisfaction are described. All analyses were performed with the use of SAS software (version 9.4; SAS Institute, Cary, NC).
Results
From October 2015 to June 2016, 91 practitioners were recruited for the study. The practitioners enrolled 358 patients, of whom 347 met the inclusion criteria.
T2 data were received for 260 patients, treated by 84 different practitioners. Twenty-four patients withdrew from the study. The remaining 63 patients did not finish treatment within the study period. T2 questionnaires were collected for 254 patients, of which 248 included patient satisfaction data. Posttreatment intraoral frontal photographs were received for 234 patients. Posttreatment lateral cephalograms were available for 231 patients. No differences were found between practitioner demographics at T1 and those at T2. Patients who completed treatment within the study period were older ( P = 0.04) and more educated ( P = 0.04) than those who did not. The pretreatment open bite severity was similar for patients who completed treatment within the study period and those who did not.
The patients had a mean age of 31.2 years (SD, 11.9 years; range, 18-71 years). Seventy-five percent of the patients were female. Just over 40% of the patients had a previous history of orthodontic treatment. The practitioners had a mean age of 48.8 years (SD, 9.8 years; range, 31-66 years). Seventy-three percent of the practitioners were male. Of the practitioners, 82 were orthodontists, and 2 were general dentists. Patient and practitioner demographics are presented in Tables I and II . Detailed demographics, describing the patients and practitioners at T1, can be found in a previously published article.
| n | % | |
|---|---|---|
| Sex (n = 253) | ||
| Male | 64 | 25 |
| Female | 189 | 75 |
| Age, y (n = 253) | ||
| 18-20 | 43 | 17 |
| 21-30 | 106 | 42 |
| 31-40 | 58 | 23 |
| ≥41 | 46 | 18 |
| Race and ethnicity (n = 253) | ||
| White | 146 | 58 |
| Black/African American | 23 | 9 |
| Asian | 24 | 9 |
| Multirace | 8 | 3 |
| Hispanic | 52 | 21 |
| Previous orthodontic treatment (n = 253) | ||
| Yes | 106 | 42 |
| No | 147 | 58 |
| Insurance coverage | ||
| None | 54 | 21 |
| Yes, does not cover orthodontics or SX | 64 | 25 |
| Yes, covers orthodontics but not SX | 74 | 29 |
| Yes, covers SX | 62 | 24 |
| Education level (n = 253) | ||
| High school graduate or less | 45 | 18 |
| Some college or associate degree | 79 | 31 |
| Bachelor’s degree | 84 | 33 |
| Graduate degree | 45 | 18 |
| n | % | |
|---|---|---|
| Status | ||
| Orthodontist | 82 | 98 |
| General practitioner | 2 | 2 |
| Sex | ||
| Male | 61 | 73 |
| Female | 23 | 27 |
| Age, y | ||
| <45 | 32 | 38 |
| 45-54 | 24 | 29 |
| 55-64 | 23 | 27 |
| ≥65 | 5 | 6 |
| Race and ethnicity (n = 83) | ||
| White | 52 | 63 |
| Asian | 19 | 23 |
| Multiracial | 2 | 2 |
| Hispanic | 10 | 12 |
| Network region | ||
| West | 34 | 41 |
| Midwest | 8 | 10 |
| Southwest | 16 | 19 |
| South Central | 6 | 7 |
| South Atlantic | 9 | 11 |
| Northeast | 11 | 13 |
The mean pretreatment overbite, measured using the lateral cephalograms, was −2.3 mm (SD, 2.1 mm). All 4 incisors exhibited no vertical overlap (POSI ≥4) in nearly two thirds of the sample. Thus, most patients had significant AOBs before treatment.
Twenty-nine patients were treated only with clear aligners. One hundred fifty-two patients were treated with fixed appliances without TADs or SX. Twenty patients were treated with TADs without SX. Fifty-three patients were treated with SX. Extractions were performed in 49 patients. Treatment spanned an average of 24.8 months (SD, 11.3 months; range, 1-72 months). At T2, 84% of patients fell into POSI category 0, indicating that the open bite was successfully closed. The mean posttreatment overbite was 1.3 mm (SD, 1.1 mm). Additional details on treatment success can be found in a concomitant publication.
High satisfaction levels were observed at T2. Specifically, 238 patients (96%) reported being satisfied with the orthodontic treatment provided as well as the final esthetic and functional results. Only 10 patients (4%) were not satisfied with the treatment or an element of the final result ( Table III ). Four of these patients were not satisfied with multiple aspects of treatment. Nearly 98% of patients would recommend treatment to a friend with a similar malocclusion ( Table III ). Likert-type scale responses to satisfaction with the treatment provided, esthetics, and function are detailed, separately, in the following section ( Supplementary Table II ).
| n | % | |
|---|---|---|
| Satisfied (n = 245) | ||
| On all | 235 | 96 |
| Not on all | 10 | 4 |
| Recommend treatment (n = 246) | ||
| Would | 240 | 98 |
| Would not | 6 | 2 |
Only 1 patient reported being dissatisfied with the orthodontic treatment provided. Two patients did not respond. Only 1 patient indicated being dissatisfied with the final esthetic result. Five patients were neither satisfied nor dissatisfied with their ability to chew at T2. Two patients were dissatisfied with their ability to chew. Six patients were neither satisfied nor dissatisfied with their speech after treatment was completed. Two patients did not specify a response for each question related to function.
Because of the small number of dissatisfied patients, there was insufficient statistical power to investigate factors associated with patient satisfaction. Several trends were observed. First, patients who did not have a successful result were more likely to be dissatisfied ( Table IV ). The strength of this relationship varied with the measure of treatment success. Patients treated with clear aligners only or SX reported higher levels of dissatisfaction than those treated with other modalities ( Table V ). Female patients were more than twice as likely to be dissatisfied with the orthodontic treatment provided or an element of the final results ( Table VI ). Patients with a higher level of education were more likely to be dissatisfied ( Table VI ). No trends were observed between patient satisfaction and practitioner characteristics. Compared with satisfied patients, dissatisfied patients were much less likely to recommend the treatment that they received to a friend with a similar malocclusion ( Table IV ). The 80% difference almost reached statistical significance.
