ORIGINAL ARTICLE

Influence of orthodontic treatment on

adolescents’ self-perceptions of esthetics
Daniela Feu,a Branca H. Oliveira,b Roger K. Celeste,c and Jose Augusto M. Migueld
Rio de Janeiro and Porto Alegre, Brazil

Introduction: The aim of this prospective evaluation was to assess changes in esthetic self-perception of
Brazilian adolescents who were receiving fixed orthodontic treatment during a 2-year period. Methods: The
treatment group consisted of 92 patients, ages 12 to 15 years, treated at the Rio de Janeiro State University or-
thodontic clinic. The control group consisted of 226 untreated adolescents; 124 subjects were waiting for treat-
ment at this clinic, and 102 subjects were attending public school and had never undergone or sought treatment.
The index of orthodontic treatment need was used to assess malocclusion severity, esthetic status (measured
by an orthodontist), and esthetic self-perception. All subjects were interviewed 3 times during the study: at
baseline; 1 year after placement of the fixed appliance for the treatment group and 1 year after the first
interview for the school and waiting groups; and 2 years after placement of the fixed appliance for the
treatment group and 2 years after the first interview for the school and waiting groups. The index of
orthodontic treatment need scores were analyzed by using negative binomial regression in generalized
estimating equations for correlated data. Results: During the follow-up period, the treatment group’s esthetic
self-perception scores had a statistically significant decrease (P \0.01), the waiting group’s scores had an
increase (P 5 0.08), and the school group’s scores were stable (P 5 0.79). At baseline, the treatment group
had an esthetic self-perception score of 96% (risk ratio 5 1.96; 95% confidence interval, 1.70-2.26) higher
than the school group, but at the final interview, the treatment group’s score was 20% lower (risk ratio 5
0.81; 95% confidence interval, 0.68-0.96) than the initial score of the school group. Age; sex; the index of
decayed, missing, and filled teeth; and socioeconomic position did not affect the adolescents’ esthetic self-
perceptions at follow up, but malocclusion severity and the group had a significant interaction. Conclusions:
Fixed orthodontic treatment in patients 12 to 15 years of age significantly improved their esthetic self-percep-
tions. (Am J Orthod Dentofacial Orthop 2012;141:743-50)

I
t has long been recognized that many people seek
and undergo orthodontic treatment not to address
dental irregularities that might lead to physiologic
dysfunction or to prevent destruction of tissues in
the oral cavity, but to improve esthetic impairment.1-6
In studies of children preparing for orthodontic
a
MSc, PhD student, Department of Preventive and Community Dentistry, Rio de
Janeiro State University, Rio de Janeiro, Brazil.
b
Associate professor, Department of Preventive and Community Dentistry, Rio de
Janeiro State University, Rio de Janeiro, Brazil.
c
Associate professor, Department of Preventive and Social Dentistry, Faculty of
Dentistry, Federal University of Rio Grande do Sul, Porto Alegre, Brazil.
d
Associate professor, Department of Preventive and Community Dentistry, Rio de
Janeiro State University, Rio de Janeiro, Brazil.
The authors report no commercial, proprietary, or financial interest in the prod-
ucts or companies described in this article.
Supported by the National Council of Technological and Scientific Development
(CNPq), Brazil, and the Carlos Chagas Filho Foundation (FAPERJ), Rio de Janeiro,
Brazil.
Reprint requests to: Daniela Feu, Rua da Gr
ecia 85, apt 1101, Barro Vermelho,
Vitoria, Espirito Santo, Brazil, ZIP 29057-660; e-mail, danifeutz@yahoo.com.br.
Submitted, July 2011; revised and accepted, December 2011.
0889-5406/$36.00
Copyright Ó 2012 by the American Association of Orthodontists.
doi:10.1016/j.ajodo.2011.12.025
treatment, the parents’ and patients’ concerns and
expectations about improved oral esthetics from
orthodontic treatment were strong, and sometimes
stronger than the expectations regarding improved oral
function.7,8
Even though the demand for orthodontic treatment
is mostly related to concerns about personal appearance
and esthetics,1,4,9,10 there are relatively few studies on
the effects of orthodontic treatment on the esthetic
self-perceptions of patients.11-14 There is a growing
need to assess patient well-being after treatment, but re-
search has only recently begun to address whether these
expectations about the self-perceived benefits of ortho-
dontic treatment are warranted.
Some authors found that, after orthodontic treat-
ment, adult patients reported a higher perceived treat-
ment need than did their untreated peers.15-17 One
study found no difference among treated and
untreated subjects with malocclusion, by using 3
self-perception scales, in a sample of first-year university
students who reported having or not having previous or-
thodontic treatment.11 In contrast with these findings,
743
744
Kerosuo et al12 and Bernab
e et al13 reported that ortho-
dontic treatment had a positive effect on young adults’
self-perceived dental treatment need. Both found better
self-perceived dental appearance among treated young
adults using the index of orthodontic treatment need-
aesthetic component scale18 and a visual analog scale,13
respectively. In these studies, previous orthodontic
treatment was assessed based on patients’ reports, but
the changes in patients’ occlusions, before and after
orthodontic treatment, were not known.11-13,15-17
Consequently, this component of orthodontic
treatment effectiveness remains unresolved in the
literature.
The objective of this prospective study was to assess
whether fixed orthodontic appliance therapy affects the
esthetic self-perceptions of Brazilian adolescents aged
12 to 15 years over 2 years. We also sought to determine
whether a patient’s oral clinical condition and social sta-
tus could influence this perception.
MATERIAL AND METHODS
All 225 adolescents who were scheduled to undergo
orthodontic treatment evaluation at the clinic of the De-
partment of Orthodontics at Rio de Janeiro State Univer-
sity in 2006 were eligible to participate in the study.
Because 9 parents did not allow their children to partic-
ipate (4% loss; 77.7% girls, 22.3% boys), 216 adoles-
cents comprised the source population for the
treatment and waiting groups. Only 92 adolescents
were selected by the professors of the orthodontic clinic
to start fixed appliance treatment, according to the pa-
tient’s type of malocclusion and the educational needs
and resources of the clinic. Those 92 adolescents com-
posed the treatment group. The 124 unselected adoles-
cents were added to a waiting list of eligible patients.
They composed the waiting group and could be called
at any time to begin treatment. When patients were
called, they were immediately taken out of the research
and considered a loss to the sample. The process of se-
lecting a patient for treatment was completely indepen-
dent of the research and was not influenced by it.
A third group, the school group, comprised all 124
age-matched adolescents who were enrolled in a public
school next to the university clinic. Along with the con-
sent form, their parents were sent a questionnaire asking
whether their children had already sought or undergone
orthodontic treatment. Twenty-two adolescents were
excluded because they did not bring back the consent
form or reported having previously sought or had ortho-
dontic treatment.
Thus, the study population consisted of 318 adoles-
cents, aged 12 to 15 years, distributed into 3 groups:
June 2012
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Issue 6 American Journal of Orthodontics and Dentofacial Orthopedics
Feu et al
treatment group (n 5 92), waiting group (n 5 124),
and school group (n 5 102). There was no sample size
calculation, since all eligible subjects were recruited. As-
suming a normal distribution, this study had 100% of
power to detect a statistically significant difference
over time at P \0.01, with baseline sample of 87
subjects (treatment group over time), and 2 repeated
measures for the index of orthodontic treatment need-
esthetic component, with the means and standard devi-
ations observed (at baseline, 4.09 [SD, 6 2.11]; after 2
years, 1.26 [SD, 6 0.56]).
All subjects completed 3 interviews and clinical eval-
uations. The first data collection occurred before the be-
ginning of the treatment for the treatment group and
was contemporaneous with the first interviews of the
waiting and school groups in 2006 (T1). The second
time of data collection occurred 1 year after placement
of the fixed appliances for the treatment group and 1
year after the first interviews of the school and waiting
groups (T2). The third data collection took place 2 years
after placement of the fixed appliances for the treatment
group and 2 years after the first interviews of the school
and waiting groups (T3).
One trained orthodontist (D.F.) collected the data.
Malocclusion severity and orthodontic esthetic impair-
ment were measured by using the dental health compo-
nent and the aesthetic component of the index of
orthodontic treatment need, respectively.18 Esthetic im-
pairment, measured by the index of orthodontic treat-
ment need-aesthetic component, was also evaluated
by the adolescents themselves. Dental health status
was determined by using the index of decayed, missing,
and filled teeth according to the World Health Organiza-
tion’s diagnostic criteria.19 Socioeconomic status was
measured with the Brazil Economic Classification Crite-
ria, which classifies people into 5 socioeconomic
categories (ie, A and B, high socioeconomic status; C,
medium socioeconomic status; D and E, low socioeco-
nomic status) according to the educational level of the
head of the household, and the ownership and con-
sumption of common goods and services (eg, VCRs,
DVDs, color TVs, maid).20
The students in the school group were examined in
their school’s dental office under conditions similar to
those of the university where the treatment and the
waiting groups were examined and by the same ortho-
dontist. The examiner (D.F.) had been trained in the
use of the index of orthodontic treatment need by a se-
nior researcher (J.A.M.M.) (gold standard) with broad ex-
perience with this occlusal index. The senior researcher
had been previously calibrated for the index of ortho-
dontic treatment need assessment in a course taken at
the University of Manchester in the United Kingdom.
Feu et al 745

Table I. Clinical and sociodemographic characteristics Table II. Changes in mean scores of AC-self over the
of the subjects by group at T1 follow-up period by group
School Waiting Treatment Initial One year Two years P
Groups (T1) later (T2) later (T3) value*
% n % n % n IOTN-AC, self-perceived
Sex School (n 5 96) 1.9 2.0 2.0 0.79
Male 41.2 42 48.4 60 51.1 47 Waiting (n 5 101) 3.9 4.0 4.4 0.08
Female 58.8 60 51.6 64 48.9 45 Treatment (n 5 87) 4.1 2.8 1.3 \0.01
Socioeconomic status*
A1, A2 0 0 2.4 3 0 0 Results retrained of those with complete data over time.
B1 2.0 2 12.9 16 3.3 3 IOTN, Index of orthodontic treatment need; AC, aesthetic compo-
B2 16.7 17 22.6 28 10.9 10 nent.
C1 65.7 67 55.7 69 23.9 22 *Friedman test for ranking variables with repeated measurements;
C2 0 0 0 0 59.8 55 the P values represent differences between any pair of years of
D, E 15.7 16 6.5 8 2.2 2 follow-up, not trend.

Mean n Mean n Mean n

Age (y) 13.7 102 13.7 124 13.4 92
(T1, T2, T3). The group variable (school, treatment,
IOTN-DHC 3.0 102 3.4 124 3.5 92
IOTN-AC, examiner 3.9 102 4.5 124 4.6 92 and waiting list) was the exposure of interest. Sex; age
IOTN-AC, self-perceived 1.9 102 4.0 124 4.1 92 at baseline; index of decayed, missing, and filled teeth;
DMFT 1.3 102 1.4 124 1.5 92 index of orthodontic treatment need-dental health com-
IOTN, Index of orthodontic treatment need; DHC, dental health
ponent; and economic class were considered as potential
component; AC, aesthetic component; DMFT, index of decayed, confounding factors. The adjusted model was based on
missing, and filled teeth. backward stepwise regression with P .0.20 for removal.
*Brazil Economic Classification Criteria.20 All analyses were performed with Stata software (ver-
sion 11.2; StataCorp, College Station, Tex). Descriptive
The training process included examination of a set of 20 statistics were used to describe the main characteristics
plaster casts by both the examiner and the senior re- of the study population. Differences in the distribution
searcher, and subsequent comparison of their results. of the covariates among the groups were tested by using
To assess intraexaminer reliability, 26 adolescents were a nonparametric test suitable for repeated measure-
reinterviewed and reexamined within 7 to 10 days of ments and ordinal variables when appropriate.
the first assessment.
This research was approved by the ethics research RESULTS
committee of Rio de Janeiro State University (1417 For both the dental health component (kappa 5 0.88
CEP/HUPE) where this study was performed, and the [95% CI, 0.86-1.0]) and the aesthetic component
parents received a letter describing the study and re- (kappa 5 0.81 [95% CI, 0.79-1.0]) of the index of ortho-
questing consent for their children to participate. dontic treatment need, the examiner showed good
agreement with the senior researcher. Intraexaminer re-
Statistical analysis liability indicated a substantial consistency of the clinical
The main outcome variable was the index of ortho- measurements (kappa 5 0.98 for the aesthetic compo-
dontic treatment need-aesthetic component of each nent [95% CI, 0.96-1.0]; kappa 5 0.96 [95% CI, 0.90-
subject, analyzed as a discrete variable. Preliminary anal- 1.0] for dental health component; and kappa 5 1.0
ysis showed that the index of orthodontic treatment for the index of decayed, missing, and filled teeth).22
need-aesthetic component followed an overdispersed The kappa coefficient for the aesthetic self-perception
Poisson distribution (likelihood test of overdispersion, was 0.93 (95% CI, 0.90-1.0), and the test-retest reliabil-
P\0.001). Therefore, we used negative binomial regres- ity values for the aesthetic self-perception were similar
sion.21 Alternative models, such as ordinal logistic among the 3 groups.
regression, did not converge. The exponentiated coeffi- At T1, the mean ages of the subjects in the treatment,
cients can be interpreted as mean score ratios. To factor waiting, and school groups were 13.4, 13.7, and 13.7
in the temporal correlation of the 3 assessments, we used years, respectively. Overall, the 3 groups were balanced
generalized estimating equations with fixed coefficients for sex and scores on the index of decayed, missing,
(population-average model) and a first-order auto-re- and filled teeth. However, differences were observed in
gressive covariance structure.22 In this way, we clustered socioeconomic status distribution, dental health compo-
the observations of each subject in temporal order nent, aesthetic component-examiner, and aesthetic

American Journal of Orthodontics and Dentofacial Orthopedics June 2012
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746
School, Baseline
60
40
20
0
Waiting list, Baseline
60
Percent
40
20
0
Treatment, Baseline
60
40
20
0
0 2 4 6
Index of Orthodontic Treatment Needs
Graphs by Groups and Timing
Fig 1. Histogram of the index of orthodontic treatment need-dental health component scores according
to groups and time of evaluation.
component-self scores. Self-perceived esthetics and
malocclusion severity were worse in the treatment and
waiting groups (Table I). The scores of the index of de-
cayed, missing, and filled teeth were low, and the pro-
portion of decayed, missing, and filled teeth was
generally higher in the posterior areas than in anterior
areas in all groups (data not shown).
Dropout rates were 5.4% (5 adolescents) in the treat-
ment group, 18.5% (23 adolescents) in the waiting
group, and 5.9% (6 adolescents) in the school group.
Of the 33 subjects who were lost to follow-up, 17 were
from the waiting group and were excluded because
they had started treatment in other places, such as pri-
vate clinics; 8 subjects changed addresses, and 8 subjects
failed to complete the study. Therefore, our analysis was
based on 852 observations clustered in 284 subjects
(treatment group, 87; waiting group, 101; and school
group, 96).
At T2 and T3, important differences were observed in
the dental health component, aesthetic component-
examiner, and aesthetic component-self scores
(Table II; Figs 1-3). The dental health and aesthetic
components scores were significantly reduced by
averages of 3.0 and 3.1 points, respectively, in the
group that received orthodontic treatment compared
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Feu et al
School, One year after School, Two years after
Waiting list, One year after Waiting list, Two years after
Treatment, One year after Treatment, Two years after
0 2 4 6 0 2 4 6
with the groups that did not, each of which had no
changes. Both differences were statistically significant
(P \0.01). The data distributions are better visualized
in the histograms (Figs 1 and 2).
Esthetic impairment improved in the treatment
group and remained stable in the school group during
the follow-up time. In the treatment group, aesthetic
component-self scores at T3 had a severely positively
skewed distribution, indicating a perception of little or
no need for treatment. In the waiting group, esthetic
self-perception scores worsened, even though there
were no changes in the patients’ esthetics according to
the examiner’s evaluation. Malocclusion severity
changed only in the treatment group (Fig 3; Table II).
The unadjusted results showed that sex; age; scores
on the index of decayed, missing, and filled teeth;
and socioeconomic status were not associated with
the adolescents’ esthetic self-perceptions (Table III).
Younger teenagers had significantly worse aesthetic
component-self scores, but the association between
age and aesthetic component-self scores disappeared af-
ter adjustment for orthodontic treatment needs. There
was an interaction between time and the groups, mean-
ing that the relative difference among the groups varied
over time. Malocclusion severity also showed an
American Journal of Orthodontics and Dentofacial Orthopedics
Feu et al
School, Baseline
80
60
40
20
0
Waiting list, Baseline
80
60
Percent
40
20
0
Treatment, Baseline
80
60
40
20
0
0 5 10 0 5
Aesthetic Component (Normative)
Graphs by Groups and Timing
Fig 2. Histogram of the index of orthodontic treatment need-aesthetic component-examiner scores ac-
cording to groups and time of evaluation.
important interaction; an increase of 1 point on the den-
tal health component scale was associated with an in-
crease of 1.32 times in the aesthetic component-self
score in bivariate analysis, and this relationship was
maintained after adjustment (risk ratio 5 1.12; 95%
CI, 1.07-1.17). No other interactions were found.
DISCUSSION
The literature suggests that orthodontic treatment
could bring many psychosocial benefits, including im-
provement in esthetic perception and reduction of social
anxiety.1,23-25 This study’s main finding was that
esthetic self-perception improved significantly with or-
thodontic treatment, corroborating the finding of
Shaw et al.14 On the other hand, adolescents who sought
treatment and did not receive it (waiting group) had
a relevant, but not statistically significant, worsening
of the index of orthodontic treatment need-aesthetic
component-self score, even though no changes were
found in their clinical malocclusion severity.
In an observational study, Shaw et al14 found that,
among patients with prior needs for orthodontic treat-
ment, those who received it were significantly more sat-
isfied with their teeth than those who did not, and this
American Journal of Orthodontics and Dentofacial Orthopedics
747
School, One year after School, Two years after
Waiting list, One year after Waiting list, Two years after
Treatment, One year after Treatment, Two years after
10 0 5 10
effect lasted over 20 years. Removable or fixed appli-
ances were used, but residual treatment needs were
found for these treated patients, and the scores of the re-
maining malocclusion were assessed by using the index
of complexity, outcome, and need. The treated cohorts
reported greater satisfaction with the appearance of
their teeth than did their peers after 20 years. In our
study, the dental health component and the aesthetic
component-examiner scores showed good improvement
in malocclusion severity after fixed orthodontic treat-
ment, suggesting no need for residual treatment. Inade-
quate completion of orthodontic treatment might
explain why Mandall et al5 found no differences in
self-perceptions among treated and untreated subjects.
The treated patients were identified through self-
reports with no information about the kind of orthodon-
tic treatment they had received or the occlusal records
from before and after treatment.
Previous studies about improvement of self-
perceived esthetics and orthodontic treatment have
shown inconsistent results, such as worsened esthetic
self-perceptions,15-17 no differences,11 or better re-
sults12-14 for orthodontically treated patients compared
with untreated subjects. There are several possible
reasons for these contradictory findings. Patients with
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748
School, Baseline
80
60
40
20
0
Waiting list, Baseline
80
60
Percent
40
20
0
Treatment, Baseline
80
60
40
20
0
0 5 10
Aesthetic Component (Self-reported)
Graphs by Groups and Timing
Fig 3. Histogram of the index of orthodontic treatment need-aesthetic component-self scores accord-
ing to groups and time of evaluation.
mild orthodontic problems might have held high
expectations for treatment, but the treatments for their
conditions could have been less effective than they
expected. Also, the malocclusion could have relapsed at
the time of the interview.16 In these previous studies,
the normative treatment need at baseline and the occlu-
sal condition at the interview were unknown.
Concerns about self-perceived esthetics represent
important psychosocial dimensions of health.5,26 In
a 15-year follow-up, subjects with untreated severe mal-
occlusions experienced continued feelings of dissatis-
faction with their teeth, and memories of teasing
persisted into adulthood, highlighting the importance
of improved self-perceived esthetics for patients’ daily
lives.27 Because in the studies of Shaw et al14 and
Bernab
e et al13 the patients were not followed during
their treatments, our results could be considered more
representative. However, once we saw great improve-
ment in the aesthetic component-self for the treatment
group, we cannot rule out the possibility that some of
the improvement in the esthetic self-perceptions was
caused by the increased attention that the patients re-
ceived, since they had frequent appointments with or-
thodontists, whereas the subjects in the waiting and
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Feu et al
School, One year after School, Two years after
Waiting list, One year after Waiting list, Two years after
Treatment, One year after Treatment, Two years after
0 5 10 0 5 10
school groups did not. Further studies are needed to in-
vestigate this possibility.
During follow-up, the waiting group had worsened
esthetic self-perceptions without changes in their clini-
cal malocclusions compared with the school group.
This result might be due to different behaviors and atti-
tudes between persons seeking treatment and those who
do not seek treatment, as stated by Albino et al,1 Man-
dall et al,5 Chavers et al,28 and Miguel et al.10 The
same malocclusion can be perceived in different
ways.29,30
When Shaw et al14 found little objective evidence to
support the long-term effects of orthodontic treatment
on psychological health, they questioned whether be-
havioral differences in the people who sought and did
not seek orthodontic treatment in their study could
have influenced this result. They believed that a low val-
uation of dental alignment or unwillingness to comply
with treatment must have influenced the decision about
treatment and might have diminished any potential for
psychological benefit to be realized. Also, subjects with
unmet and high objective needs for treatment had
higher scores on the index of decayed, missing, and filled
teeth at 11 years of age, suggesting some inherent
American Journal of Orthodontics and Dentofacial Orthopedics
Feu et al 749

diversity, we believe that it would be prudent not to gen-

Table III. Crude and adjusted associations between
eralize our results to the general population of Brazilian
IOTN-AC self-perceived scores and covariates over 2
adolescents who seek or receive orthodontic treatment.
years of follow-up from negative binomial regression
in generalized estimating equation models
CONCLUSIONS
Adjusted*
IOTN-AC, Crude score ratios score ratios Fixed orthodontic treatment improved the esthetic
self-reported 95% CI 95% CI self-perceptions in Brazilian adolescents aged 12 to 15
Interaction of time and group years and patients who sought orthodontic care. Those
School
who did not receive treatment had significantly worse
Initial 1 1
One year later 1.05 (0.99-1.11) 1.05 (0.97-1.11) self-ratings. The outcome was only partly influenced
Two years later 1.05 (0.99-1.12) 1.04 (0.94-1.15) by malocclusion severity.
Waiting
Initial 2.10 (1.77-2.38) 2.00 (1.73-2.31)
One year later 2.13 (1.77-2.38) 2.03 (1.75-2.35) REFERENCES
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