ONLINE ONLY

Attractiveness, acceptability, and value

of orthodontic appliances
Michael D. Rosvall,a Henry W. Fields,b James Ziuchkovski,c Stephen F. Rosenstiel,d and William M. Johnstone
Herriman, Utah, Columbus, Ohio, and Colorado Springs, Colo

IntroductionThe aim of this study was to quantify laypersons’ assessments of attractiveness, acceptability,
and value of orthodontic appliances. Methods: Orthodontic appliances were placed in a consenting adult,
and digital images were captured, standardized, and incorporated into a computer-based survey. The survey
displayed various images of orthodontic appliances for rating by a sample of adults (n550). Subjects rated
each image for (1) attractiveness on a visual analog scale, (2) acceptability of placement of each appliance
on themselves and their children, and (3) willingness to pay for each appliance for an adult or a child relative
to a metal appliance standard. Rater reliability for the attractiveness, acceptability, and value ratings was
assessed by rating 3 images twice. Results: Overall reliability values for attractiveness were intraclass corre-
lation coefficient50.87 and k50.81 for acceptability and k50.88 for value ratings. The raters’ annual income
was not significant for attractiveness, acceptability, or value ratings. No significant difference was found be-
tween parent and child ratings for either the appliance acceptability or value ratings. Appliance brand, material,
and wire were significant factors affecting attractiveness and value ratings. Attractiveness ratings were
grouped in the following hierarchy of appliance types: alternative appliances such as clear trays and simulated
lingual appliances . ceramic appliances . ceramic self-ligation appliances . all hybrid and stainless steel
appliances. Acceptability ratings for all alternative and ceramic appliances were statistically equivalent, and
statistically higher than those for other appliances. Standard metal braces had the lowest acceptability rate
of 55%. The willingness-to-pay value of appliances relative to a metal standard appliance ranged from $629
for lingual appliances to $167 for a hybrid self-ligation appliance. Conclusions: These findings show that a
significant number of patients find commonly used appliances unattractive and unacceptable. Patients are
willing to pay more money for appliances they deem more esthetic. (Am J Orthod Dentofacial Orthop
2009;135:276.e1-276.e12)

D
ental and facial esthetics is considered a new
paradigm in diagnosis and planning for ortho-
dontic treatment.1
Although not uniformly accepted, this principle is
becoming more concrete because investigators can use
digital images to manipulate and control confounding
esthetic variables to determine patient and professional
preferences and ranges of acceptability more pre-
cisely.2-4
Patient demands for esthetic orthodontic treatment
outcomes have grown to include esthetic appliances
a
Private practice, Herriman, Utah.
b
Chairman, Division of Orthodontics, College of Dentistry, Ohio State Univer-
sity, Columbus, Ohio.
c
Private practice, Colorado Springs, Colo.
d
Professor and chairman, Division of Restorative and Prosthodontics, Ohio
State University, Columbus, Ohio.
e
Professor, Division of Restorative and Prosthodontics, Ohio State University,
Columbus, Ohio.
Reprint requests to: Henry W. Fields, 4088F Postle Hall, 305 W 12th Ave, PO
Box 182357, Columbus, OH 43218-2357; e-mail, fields.31@osu.edu.
Submitted, April 2008; revised and accepted, July 2008.
0889-5406/$36.00
Copyright Ó 2009 by the American Association of Orthodontists.
doi:10.1016/j.ajodo.2008.07.011
during treatment. Until recently, the only available
data regarding appliance esthetics were not from the
United States but showed that, although 97% of the peo-
ple surveyed wanted their malocclusions corrected,
62% rejected treatment with a visible appliance.5 A sur-
vey of 160 Swedish 27-year-old adults showed that 67%
would probably or definitely be willing to wear visible
braces if needed. Based on appearance of the braces
alone, 33% of the adults would be unwilling to wear vis-
ible braces if needed. The same group additionally re-
sponded that 84% would probably or definitely wear
visible braces during adolescence if needed.6 These re-
sponses suggest a dichotomy between acceptability of
orthodontic appliance for adolescents and adults.
Efforts have been made to increase the esthetic qual-
ity of orthodontic appliances. Bands with attachments
evolved into bondable brackets. Bondable brackets
were produced in ceramic and plastic. Coated, tooth-
colored wires that more closely resemble natural tooth
color can be used during part of the treatment period.
Although less visible, lingual orthodontic appliances
have some popularity. More recently, plastic trays
were developed to gradually align the teeth. Although
276.e1
276.e2 Rosvall et al
these trays are less visible, there appear to be limits to
the types of malocclusion that they can efficiently cor-
rect.5,7,8 Self-ligating appliances also come in an es-
thetic type that combines the esthetic qualities of
ceramic and plastic brackets and the reduced friction
of the self-ligating mechanism.
At this time, only 1 study has compared laypersons’
perceptions of the esthetic qualities of the various cur-
rent orthodontic appliances.9 This study examined ap-
pliance attractiveness and found a hierarchy of
appliance types: alternative appliances (clear trays and
lingual appliances) . ceramic appliances . all stainless
steel and self-ligating appliances, with a few differences
in each type of appliance. Furthermore, the acceptabil-
ity of appliances can also be determined. Acceptability
includes more than attractiveness. This concept was ex-
plored by Parekh et al10 when evaluating smiles; they
obtained different results from attractiveness. The pref-
erences for appliances can be explored in terms of their
economic value to patients.
Several methods have been studied to evaluate the
economic value of medical interventions, including
cost-minimization, cost-effectiveness, cost-utility, and
cost-benefit analyses. Cost-benefit analysis is believed
to be the most comprehensive and theoretically sound
form of economic evaluation.11-13 Willingness to pay
(WTP) is a way of measuring benefit in monetary terms
in a cost-benefit analysis. It assigns monetary values to
both costs and outcomes of health care and calculates
the net benefit. WTP allows a monetary rating to be at-
tached to novel health care interventions or outcomes by
asking people how much they would pay to obtain the ben-
efits of treatment or to avoid the negative aspects of an ill-
ness. This value is set as raters are asked to respond to
a hypothetical, conditional question—eg, ‘‘what is the
maximum amount you would be willing to pay to access
a new intervention, were it to become available?’’
Although the same general question is asked any WTP
study, the question can be asked in various formats.
Initially, most studies posed the valuation question
in an open-ended format, allowing subjects to suggest
their own maximum WTP with no prompting or guid-
ance to the appropriateness of the values to be chosen.
In recent years, 3 new variations have been used. First
is the payment scale method, when subjects select
a maximum WTP value from a prespecified and ordered
list. Second is the bargaining or bidding format, when
the investigator offers WTP values that the subject ac-
cepts or rejects, and new values are offered until the
maximum WTP value is determined. Third is the dis-
crete choice, or closed-ended format, when the subject
has an accept-or-reject choice at a predetermined
WTP offer, with varying amounts for each subject. A
American Journal of Orthodontics and Dentofacial Orthopedics
March 2009
recent study compared each of these methods, and the
authors concluded, ‘‘The most informative format in
the present context is likely to be the one yielding the
most conservative results, on the grounds of both risk-
aversion in decision-making and potential minimization
of over-valuation due to hypothetical bias. On the basis
of our results, this would appear to be the open-ended
format. Although the payment scale format yielded
broadly similar policy conclusions, it is evident that
the results were sensitive to the choice of an appropriate
scale length.’’14 When applied to orthodontics, these
methods provide a way to determine the value of differ-
ent appliances to the patient.
The overall objectives of this research were to vali-
date orthodontic bracket attractiveness, determine the
range of acceptability of the appliances, and establish
the value of orthodontic appliances.
MATERIAL AND METHODS
The institutional review board of Ohio State Univer-
sity approved this research, designed as a computerized
survey that displayed various images of orthodontic ap-
pliances for rating by a sample of adults in the central
United States. This study was an extension of the orig-
inal research of Ziuchkovski et al9 with the same
methods. In addition to the original appliances exam-
ined in the parent study, another was added (In-Ova-
tion-C, GAC International, Bohemia, NY), and the
value of esthetics in monetary terms was evaluated.
A summary of the replicated methods is provided
here. For more detail, the reader is referred to the orig-
inal article.9 New methods are described in detail.
A model was selected for application of orthodontic
appliances and image capture on the basis of good align-
ment of teeth and absence of strong sex markers in the
circum-oral region. Alginate impressions were obtained
of the model’s maxillary dentition and used for fabrica-
tion of appliance placement jigs that allowed for precise
and repeatable placement of orthodontic appliances. All
images were captured with a custom camera jig (D100
digital camera equipped with a Nikkor 24- to 85-mm
macro lens and SB-29s Macro Speedlight, (Nikon,
Melville, NY). The camera was manually set, with all
image adjustment features turned off, and held constant
for all captured images. The color mode was set to
Adobe RGB (Adobe Systems, San Jose, Calif) and the
image quality to RAW (NEF files). A GretagMacbeth
Mini ColorChecker (GretagMacbeth, Grand Rapids,
Mich) was fastened to the jig to allow for color calibra-
tion. While the images were captured, all lighting was
turned off with the exception of a lamp (6500 K,
Ideal-Lume, Denver, Colo) placed in a fixed location.
American Journal of Orthodontics and Dentofacial Orthopedics
Volume 135, Number 3
Fig 1. Several standardized appliance images used in this study. Note the consistency among the
images and the soft-tissue drape.
All appliances were bonded to the model’s maxil-
lary dentition (second premolar to second premolar)
by using light-cured adhesive (Transbond XT, 3 M Uni-
tek, Monrovia, Calif) and self-etching primer (Trans-
bond Plus, 3M Unitek). The wires were 14-mil
Sentalloy nickel-titanium (GAC International) (stan-
dard) and 14-mil Spectra Epoxy coated nickel-titanium
(white), ligated with AlastiK (3M Unitek) clear liga-
tures. A clear tray (Essix appliance, Raintree Essix,
Metairie, La) was imaged to simulate clear tray align-
ment systems such as Invisalign (Align Technology,
Santa Clara, Calif). A control image was captured with-
out appliances to simulate lingual appliances. Extraoral
images of the perioral region were also captured with
the model smiling for later use as a smile layer.
All images were standardized for color and format
with Adobe Photoshop (version 7.0) and the Pictocolor
InCamera (version 4.0.1, Pictocolor, Burnsville, Minn)
plug-in software. With the InCamera software, a custom
International Color Consortium color profile was cre-
ated and applied to each image by using the GretagMac-
beth Mini ColorChecker color patches as standard
reference. This process standardized all images to the
standard color reference patches. To limit confounding
variables, a standard smile layer was created and placed
over each intraoral appliance image to create images
with variable orthodontic appliances and constant
soft-tissue features. The position of the intraoral image
with reference to the smile layer was standardized by
best fitting the images to vertical and horizontal refer-
ence lines.
Rosvall et al 276.e3
Constant position and size of the intraoral images
were verified by toggling between all intraoral layers
in the Photoshop program. The consistent position of
the archwires was verified with this same technique to
ensure similar smile-arch characteristics. Examples of
several images are shown in Figure 1.
The standardized images were incorporated into
a web-based survey with Quask FormArtist Standard
software (version 3.7, Quask, Princeton, NJ). All im-
ages were attached to the survey with the least amount
of image compression allowed by the software. The im-
ages were presented at approximately life size.
The survey design consisted of a script introduction,
age verification, demographic collection, instructions,
and image-rating pages. Each page was navigated by
simple ‘‘click here to continue’’ buttons. The optional
demographic collection page consisted of a drop-down
menu for reporting the rater’s household income.
The instruction pages gave a short tutorial on how to
complete the survey. During this sequence, all images
were displayed for at least 6 seconds to acquaint the sub-
ject with the range of images to be evaluated later in the
survey. The instruction pages were interactive and re-
quired completion of a sample question before starting
the survey.
The image-rating pages consisted of a visual analog
scale (VAS) and 2 yes/no acceptability questions for
each image. The VAS was used to assess appliance at-
tractiveness and was presented first in the sequence of
questions. The VAS was anchored by the phrases ‘‘ex-
tremely attractive’’ and ‘‘extremely unattractive.’’ It
276.e4 Rosvall et al American Journal of Orthodontics and Dentofacial Orthopedics
March 2009

Fig 2. An attractiveness and acceptability appliance image-rating page with the VAS and acceptabil-
ity questions completed.

Fig 3. A WTP value-rating page.

was 100 mm long and scored by pixel values on the
computer screen. The subject placed an orange vertical
mark on the scale to rate the image. Use of the VAS in
this manner made it possible to continuously score the
data. The yes/no questions, used to assess appliance ac-
ceptability, asked, ‘‘If you were to have orthodontic ap-
pliances (braces) placed on your teeth, would the ones
pictured above be acceptable in appearance?’’ The sec-
ond question was, ‘‘If your child were to have orthodon-
tic appliances (braces) placed on his/her teeth, would
the ones pictured above be acceptable in appearance?’’
A sample rating page is shown in Figure 2.
After the attractiveness and acceptability questions,
a final question was asked that sought to determine the
American Journal of Orthodontics and Dentofacial Orthopedics Rosvall et al 276.e5
Volume 135, Number 3

Table. Summary of ANOVA for the VAS ratings whether they were familiar with a computer mouse.
Class/level information
They completed the survey in a darkened room with
the exception of the 6500 K lamp behind the computer
Class Level Values monitor. The computer monitor was calibrated for color
Wire 3 None, stainless steel, and white with the X-Rite Monaco Optix XR Pro monitor calibra-
Brand 9 Clarity, control, Damon 3, Essix, tion package (XRite, Grand Rapids, Mich) and allowed
Ice (Ormco Corp, Orange, to warm up for at least 30 minutes every day before col-
Calif), In-Ovation-C, lecting data. With the Quask FormArtist standard soft-
In-Ovation-R, Mystique (GAC
ware, all data were collected on a secure server and
International), and Ovation
Material 5 Ceramic, control, hybrid, plastic, retrieved later for analysis.
and stainless steel Fifty adults completed the computer survey. Demo-
Design 2 Self-ligating and standard graphically, the subjects had with household incomes of
less than $50,000 per year (36%) and more than $50,000
Tests of fixed effects
per year (54%); 10% did not report their income level.
Numerator Denominator F P
Effect (df) (df) ratio value
Statistical analysis
Material 3 637 61.02 \0.001
Wire 1 637 17.31 \0.001 Intrarater reliability of the VAS ratings was evalu-
Wire x material 1 637 2.19 0.139 ated by the average intraclass correlation coefficient cal-
Design 1 637 0.09 0.767
culated for each judge.15 VAS ratings were analyzed by
Brand (material x design) 3 637 10.16 \0.001
Wire x brand 3 637 0.22 0.886 using a linear mixed model analysis of variance (AN-
(material x design) OVA) with repeated measures to account for any missing
data. For all studies, the main effect of the demographic
factor (household income) and its interaction with the
perceived value of each orthodontic appliance by using images being rated was first tested for significance.
the WTP method. The question, shown in Figure 3, con- Because household income was not significant for any
sisted of a page illustrating a standard orthodontic appli- study, it was removed from the model to allow for incor-
ance (Ovation with a standard wire and clear ties) poration of data when the demographic responses were
labeled ‘‘Picture A’’ and one of similar size with another missing. Subsequent analysis was performed on the
orthodontic appliance labeled ‘‘Picture B.’’ The rater re- VAS ratings for the appliance variables (appliance
ceived these instructions: ‘‘Assume that orthodontic type, brand of appliance type, wire, design) again by
treatment with the braces shown in Picture Awill require using factorial ANOVA with repeated measures. Post-
24 months of treatment to straighten your teeth and cost hoc testing of the least squares means was done with
$4500.’’ Then the rater was asked, ‘‘Assume the braces in the Tukey-Kramer method. The level of significance
picture B are more expensive than those in Picture A. was set at a50.05. Statistical analyses were calculated
How much more money would you be willing to pay with SAS software (version 9.1, SAS, Cary, NC).
for them to be placed on YOUR teeth?’’ After that ques- Reliability of yes/no responses for adult and child
tion, a second question asked how much more money the acceptability was assessed by the kappa statistic. The
rater would be willing to pay to have Picture B braces Fisher exact test was used to determine significant dif-
placed on ‘‘your child’s teeth.’’ The rater could check ferences between parent and child acceptability re-
a box to represent the amount he or she would pay for sponses. Because no significant relationship was
Picture B braces, ranging from $100 to $1500 in $100 in- found, all images were pooled to obtain the frequency
crements. Alternatively, if the rater would not pay addi- of acceptability for all images. The Fisher exact test
tional money for the appliances in Picture B, he or she was used to determine significant differences between
could select, ‘‘None, I would prefer Picture A braces.’’ acceptance rates for each image. Step-down Bonferroni
All image-rating pages were presented randomly to correction was applied when multiple comparisons
each rater. Three image-rating pages, previously shown were performed (overall a \0.05). Statistical analyses
to represent the high, middle, and low ranges of attractive- were calculated with the SAS software.
ness, were shown twice to evaluate intrarater reliability. Intrarater reliability for the value responses was de-
Each survey was administered on a designated com- termined by using the weighted kappa statistic. Value
puter in a private room adjacent to the clinic. All raters responses for adult and child ratings were analyzed
were anonymous, and no record of their identities was with a linear mixed model ANOVA with repeated mea-
made. Before starting the survey, all subjects were asked sures. Because no statistically significant relationship
276.e6 Rosvall et al
Fig 4. The mean VAS ratings for appliances imaged with a steel wire. The solid lines connect appli-
ances that have statistically similar means at the P\0.05 level. The standard deviation is noted for
each appliance.
was found, all responses were pooled and analyzed by
using the least squares method to obtain an estimate
of the value for each image to account for any randomly
missing data. Post-hoc testing of the least squares means
was done with the Tukey-Kramer method. The level of
significance was set at a50.05. Statistical analyses were
calculated with the SAS software.
RESULTS
The results indicate that intrarater reliability was
high for the attractiveness (mean ICC [3,1]50.87), ac-
ceptability (k50.81), and value (k50.88) portions of
the study. A summary of the ANOVA for the VAS scores
is given in the Table. The mean VAS scores for each ap-
pliance with a ligated steel wire are shown in Figure 4.
Attractiveness was greater as the VAS scores increased.
Figure 5 displays the results of the appliances imaged
with a ligated white wire, and Figure 6 gives the results
of all appliance and wire combinations. The data show
a general statistical hierarchy, with attractiveness de-
creasing as the amount of metal displayed increases.
The pooled acceptability rates for each appliance
with a ligated steel wire are shown in Figure 7. Figure 8
gives the acceptability results of the appliances imaged
with a ligated white wire, and Figure 9 demonstrates the
results of all appliance and wire combinations. Overall,
the acceptability for all alternative and ceramic appli-
American Journal of Orthodontics and Dentofacial Orthopedics
March 2009
ances was high, with acceptability rates over 80%.
The Ovation bracket, chosen to represent all standard
stainless steel brackets, had the lowest acceptability
rate of 55%.
The pooled least squares mean estimates representing
the additional amount of money the respondent would be
willing to pay for each appliance (compared to 24 months
of treatment with a standard metal bracket (Ovation) at
the cost of $4500) are reported in Figures 10 through
12. Figure 10 shows appliances with stainless steel wires,
Figure 11 displays appliances with white wires, and Fig-
ure 12 gives all bracket and wire combinations. The appli-
ance with the highest rated value was the control image,
which simulates lingual orthodontics. The least squares
mean estimate for this appliance was $629. The appliance
with the lowest but statistically significant value com-
pared with the control was the Damon 3 bracket (Ormco,
Glendora, Calif) with a steel wire. The least squares mean
estimate for this appliance was $167. No statistical differ-
ence was found between the metal self-ligating bracket
and the standard metal bracket.
DISCUSSION
Because most orthodontic treatment is performed
with a metal wire, it is clinically applicable to consider
the attractiveness of appliances with metal wires in
place. The results of the attractiveness portion of the
American Journal of Orthodontics and Dentofacial Orthopedics Rosvall et al 276.e7
Volume 135, Number 3

Fig 5. The mean VAS ratings for appliances imaged with a white wire. The solid lines connect appli-
ances that have statistically similar means at the P\0.05 level. The standard deviation is noted for
each appliance.

Fig 6. The mean VAS ratings for all appliance and archwire combinations. The solid lines connect
appliances that have statistically similar means at the P\0.05 level. The standard deviation is noted
for each appliance.

study, assessed on a VAS scale, confirm the hierarchy
established by Ziuchkovski et al,9 that attractiveness de-
creases as metal show increases. However, in addition to
the 3 statistically and clinically significant categories of
appliance attractiveness found by Ziuchkovski et al
(alternative appliances such as lingual and clear tray
appliances . ceramic appliances . all stainless and
self-ligating brackets), we found a new, statistically sig-
nificant category of ceramic self-ligating brackets with
less metal showing than previous hybrid self-ligating de-
signs. When the 12% change on the VAS rating that
Ziuchkovski et al used to identify clinical significance
was applied to these results, the In-Ovation-C appliance
became grouped with the other ceramic appliances. It is
276.e8 Rosvall et al American Journal of Orthodontics and Dentofacial Orthopedics
March 2009

Fig 7. The percentages of acceptability for appliances imaged with a steel wire. The solid lines con-
nect appliances that have statistically similar means at the P\0.05 level.

Fig 8. The percentages of acceptability for appliances imaged with a white wire. The solid lines con-
nect appliances that have statistically similar means at the P\0.05 level.

likely that this new bracket design is on the border of the
‘‘critical metal appearance’’ that seems to be distinguish-
able (the only visible metal display on the bracket is the
rhodium-coated clip that serves as the ‘‘door’’ that holds
the archwire in the bracket slot).
We did not consider aging and discoloring of clear
elastic ligature ties over the time from 1 adjustment to
another or the effect of aging of the appliances. The ef-
fect of such staining on the attractiveness of appliances
has not been scientifically established. The self-ligating
design of the In-Ovation-C and Damon 3 brackets elim-
inates the discoloring of individual elastic ties, but these
appliances are still subject to staining of the elastomeric
chain when it is used. The clear tray aligners usually do
not discolor when used for the standard 2-week period.
It would have been difficult, if not impossible, to show
all appliances at an aged time while controlling the vari-
ables and using the same model. Different times age ap-
pliances differently, and the gradual change is often not
noticed by patients. Elastomerics can be changed, but
bracket bases are not. For these reasons, initial appli-
ance appearance was compared and considered the
most unbiased presentation.
Perhaps even more important than the concept of ap-
pliance attractiveness is that of appliance acceptability.
Previous research has shown that 33% to 62% of adults
would reject treatment with a visible appliance.5,6 The
only remaining alternative available to them would be
American Journal of Orthodontics and Dentofacial Orthopedics Rosvall et al 276.e9
Volume 135, Number 3

Fig 9. The percentages of acceptability for all appliance and archwire combinations. The solid lines
connect appliances that have statistically similar means at the P\0.05 level.

Fig 10. The least squares mean estimates of the WTP value for appliances imaged with a steel wire.
The solid lines connect appliances that have statistically similar means at the P\0.05 level. The stan-
dard error is noted for each appliance.

invasive restorative treatment. The acceptability rates
reported here show that alternative appliances such as
Invisalign and lingual braces and all traditional ceramic
appliances are acceptable to over 90% of the adults sur-
veyed. The lowest acceptability rate was for the Ovation
bracket: 55%. This appliance was selected to represent
all other metal bracket systems, because previous re-
search showed that varying the size or profile of a metal
bracket has no effect on its attractiveness.9 The bracket
that represented all metal self-ligating brackets, In-Ova-
tion-R (GAC International), had the second lowest
acceptability rate—58%. It is interesting that these ap-
pliances that are most often used today were the least ac-
ceptable to the adult raters. These appliances,
considered by most orthodontists to be the most durable
and perhaps most efficient in practice, were unaccept-
able to 42% to 45% of patients.16-20 This seems para-
doxical because most appliances used are metal.
Perhaps most adults and parents are unaware of the
range of options available for treatment. During this
study, all options of appliances were shown. It is not
practical in practice for any practitioner to offer the
276.e10 Rosvall et al American Journal of Orthodontics and Dentofacial Orthopedics
March 2009

Fig 11. The least squares mean estimates of the WTP value for appliances imaged with a white wire.
The solid lines connect appliances that have statistically similar means at the P\0.05 level. The stan-
dard error is noted for each appliance.

Fig 12. The least squares mean estimates of the WTP value for all appliance and archwire combina-
tions. The solid lines connect appliances that have statistically similar means at the P\0.05 level. The
standard error is noted for each appliance.

range of appliances that the raters saw, so their opportu-
nity to make a fully informed and unbiased choice of ap-
pliance type usually does not occur. Given the breadth
of possibilities and no restriction of cost or biomechan-
ical limitations and a solely esthetically driven decision,
the results are at least plausible and probably reflect
their true preferences.
The appliances with the highest acceptability rates
in this study are often considered to be either difficult
to work with or less efficient in treatment mechanics.
A possible exception to this might be the In-Ovation-
C bracket, which showed no statistical difference in
acceptability with the other ceramic brackets. No
studies have been published regarding the friction or
other biomechanical properties of In-Ovation-C
brackets. Whether this bracket can occupy a new mar-
ket niche that offers esthetics and efficiency is yet to
be known.
American Journal of Orthodontics and Dentofacial Orthopedics
Volume 135, Number 3
In this study, parents’ perceptions of what was ac-
ceptable for themselves and their children were similar.
These results suggest that the standard for acceptable
dental esthetics for children parallels the trend of in-
creasing demand for esthetic dental treatment for adults
when parents make the decisions. Children might make
different decisions that could even be related to age.
We used the WTP method to evaluate the value of
various orthodontic appliances by means of a cost-ben-
efit analysis. We evaluated WTP using the payment
scale method rather than an open-ended format because
of the computer survey design. Previous researchers
have shown that the payment-scale format yields similar
conclusions to open ended, if the scale is of appropriate
length.14 A scale from $0 to $1500 was selected because
it was thought unlikely that practices charge more than
$1500 over the standard fee for any of the appliances
pictured. The results of the WTP values should be inter-
preted with the understanding that the reference given to
the rater was that orthodontic treatment would require
24 months of treatment with standard braces at a cost
of $4500. A recent practice survey showed that the me-
dian fees for orthodontic treatment are $4700 for a child
and $5000 for an adult; this is an 8% increase from the
previous 2 years.21 The WTP value is likely to change
with a different reference amount and possibly with
a different scale. The true monetary value of orthodontic
appliances is set by the economic market. Thus, it was
not our intent to establish or suggest pricing for various
orthodontic appliances. The WTP method was used to
show the perceived value of various orthodontic appli-
ances in a term that is more readily understood by the
rater with the hope of identifying differences between
appliances in the same category.
Although alternative appliances and ceramic
brackets were shown to be statistically equivalent in ac-
ceptability, there was a statistically significant difference
in WTP between the alternative appliances and all others.
The raters responded with the highest WTP values for lin-
gual appliances and the Essix tray, which was used to
simulate Invisalign and other clear aligners. Clearly,
there is an increased demand for these types of less visi-
ble appliances. This demand is evident in the public sec-
tor as clear tray aligners grow in popularity; even
exclusive Invisalign offices have been established.22-24
No statistically significant difference was found for
acceptance or WTP values for any appliances imaged
with either a steel or white wire. In other words, a Clarity
bracket (3M Unitek) with either a white or a steel wire is
equally acceptable and has an equal value to the rater.
These results suggest the additional cost of providing
both white and steel wires might not increase treatment
acceptance.
Rosvall et al 276.e11
Similar to the acceptability data, adults were equally
willing to pay more for appliances they deemed more
desirable for themselves and their children. The trend
appears to be an increasing demand for esthetic appli-
ance options for adults and adolescents, with WTP for
this improvement for themselves or their children. The
data collected from the attractiveness, acceptance, and
value portions of the study all refute the notion that
less attractive appliances are reasonable for adolescents
but not adults.
CONCLUSIONS
1. Orthodontic appliance attractiveness as judged by
adults varies significantly by the following appli-
ance hierarchy: alternative appliances . ceramic
appliances . ceramic self-ligating appliances .
hybrid self-ligating stainless steel and self-ligating
stainless steel appliances.
2. Alternative appliances such as Invisalign and lin-
gual braces and all traditional ceramic appliances
are acceptable to over 90% of the adults surveyed.
Traditional stainless steel and metal self-ligating
brackets are acceptable to only 55% to 58%, re-
spectively, of the adults surveyed when the know
all options.
3. WTP values show that adults are willing to pay an
additional mean amount of $610 for alternative ap-
pliances such as lingual braces and clear tray
aligners, $329 for ceramic traditional and self-ligat-
ing appliances, and $167 for hybrid self-ligating
appliances.
4. Adults showed no difference in acceptability and
WTP value ratings between themselves and their
children.
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