British Journal of Orthodontics

ISSN: 0301-228X (Print) (Online) Journal homepage: http://www.tandfonline.com/loi/yjor19

An Investigation into some of the Factors

Influencing the Desire for Orthodontic Treatment

Mary B. E. Gosney B.Ch.D., M.D.Sc., F.D.S.R.C.S. (Edin.), D.D.Orth.

To cite this article: Mary B. E. Gosney B.Ch.D., M.D.Sc., F.D.S.R.C.S. (Edin.), D.D.Orth. (1986) An
Investigation into some of the Factors Influencing the Desire for Orthodontic Treatment, British
Journal of Orthodontics, 13:2, 87-94, DOI: 10.1179/bjo.13.2.87

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British Journal of OrthodonticsfVol 13/1986/87-94
CC 1986 British Society for the Study of Orthodontics 0301-228X/86/002087 +08 S0200

An Investigation into ·some of the

Factors Influencing the Desire for
Orthodontic Treatment
Mary B. E. Gosney, B.Ch.D., M.D.Sc., F.D.S.R.C.S. (Edin.), D.D.Orth.
Orthodontic Department, Royal Victoria Hospital, Bournemouth

Abstract. A sample of 2.07 patients and their respective parents were surveyed to assess the influence various
occlusal anomalies and other factors bad bad in stimulating a desire for orthodontic treatment. From the
results obtained it is thought that more attention should be given to the particular occlusal and aesthetic
deviations which are causing concern to the patient: assumptions based purely upon the presenting occlusal
condition should be avoided.
It was shown that for the majority of patients the provision of orthodontic care was dictated largely by
aesthetics but that the general dental practitioner exerted an appreciable influence on patient acceptance of
treatment.

Introduction granted, whereas those with malocclusions may

The relationship between physical appearance and
perception of an aesthetic defect may be divided
into:
a. The impact on self esteem and body image;
b. The attitude of society and the community to the
defect.
According to Burns (1972), the concept of 'body
image' involves the development of a conscious
image of one's own appearance. This image is
usually personally pleasing, but if it is not, the
individual may develop anxieties which can even-
tually lead to psychological problems. Body image
does not often closely relate to an objective repre-
sentation of the body and the severity of a disfigure-
ment frequently bears little relationship to the
degree of anxiety it produces (MacGregor, 1970). A
minor irregularity, such as a median diastema or a
rotated lateral incisor, is capable of producing a
disproportionately less pleasing body image in one
individua~ than a gross anomaly, such as mandi-
bular prognathism, may produce in another.
Persons for whom dental appearance is impor-
tant will increase the impact this feature has on body
image when compared with individuals who possess
a low awareness of their dental appearance. It could
be hypothesized that those with an acceptable
dentition may reduce its saliency by taking it for
Jtec:eiWid for publicaliOD 16 Juae 1!185
increase the importance which this feature has on
self esteem. Previous studies have not entirely
supported this assumption as the aesthetic self-
evaluation of an appreciable number of patients,
and subsequently the need for orthodontic
treatment, did not coincide with professional
judgements (Myberg and Tbilander, 1973; Ingervall
and Hedegard, 1974; Lindsay and Hodgkins,
1983). Thus, some patients may be unaware of,
or relatively unconcerned about a pronounced
malocclusion whereas others may show great
concern over a relatively mild irregularity.
In addition to the effect of malocclusion on an
individual, it is desirable to ascertain the level of
dental aesthetics acceptable to the community. Linn
(1966), in a survey of 1862 American adults found
that, irrespective of social background, a large
proportion indicated a good dental appearance to
be important, particularly for making friends, 'dat-
ing' and employment Despite this, more than one
third of those interviewed bad uncorrected, highly
visible dental defects but showed an apparent lack
of self-consciousness. Furthermore, consideration
must be given to the discrepancy which may exist
between lay and professional judgements concern-
ing the acceptability of variations from an aesthetic
ideal (Goldstein, 1969; Sbaw et al., 1975), otherwise
treatment may be suggested by orthodontists to
Mary B. E. Gosney

improve dental appearance in cases where no In addition to the data obtained from the ques-
aesthetic handicap is apparent to the general tionnaires, the appearance of the dentition was
community. assessed by the author using study models taken
The motivation to undergo orthodontic treat- before treatment commenced. A simple aesthetic
ment usually results from psychological and social occlusal analysis was employed, based upon the
factors acting on the patient and family. From following features being visible in the upper labial
studies in America by Baldwin and Barnes (1965, segment (i.e. from canine to canine inclusive).
1966) in which over 600 patients were investigated, 1. The presence of either crowding or rotations.
treatment was being sought by a large proportion 2. The presence of spacing.
because of the mother's wishes. Resolution of 3. No visible anomaly present.
family/parental problems, status seeking and feel- 4. The overjet (recorded in mm).
ings of guilt concerning a possible hereditary cause
Only visible spacing, crowding and rotations were
for the child's orthodontic state were implicated as
recorded as such-their potential development be-
underlying influences.
ing ignored.
Lewit and Virolainen (1968) showed in a study of
129 American High School children that those with The overjet was measured in the midline from the
the severest mal occlusion had the greatest desire for labial surface of the upper central incisors (or where
treatment. However, no significant differences in applicable the labial surface of the most prominent
central incisor), to the labial surface of the lower
desire for treatment between the moderate mal-
incisors. Measurement of overjet has been shown by
occlusion and the good occlusion group were found.
Gravely (1972) to be one of the more reproducible
They observed that parental wishes were important
records that can be made and as the overjet is being
for dependant adolescents, but the more self-reliant
used in the present study as an aesthetic evaluation,
adolescents were less influenced by parental or peer
it was considered adequate to make a single measure-
approval, than by severity of malocclusion.
ment for each patient. A simple aesthetic assessment
If, as these studies suggest, motivation and the
was employed since Katz (1978) showed that use of
decision to seek treatment are not always initiated
an occlusal feature index evaluating only a few
by the child, the incentive to co-operate fully
salient variables, provided the most meaningful and
during the treatment period may be reduced or
consistent method of objectively recording the
absent. Most ofthe studies investigating the psycho-
occlusal status for use in assessments of dental
sociological motivating factors which influence
appearance. His detailed investigation also con-
the provision of orthodontic treatment have been
firmed what commonsense would dictate-that
carried out in the USA and relatively little attention
satisfaction with one's dental appearance is related
has been devoted to this aspect in Great Britain.
to factors which are most visible and most easily
assessed by the lay person.
The patients for their part were asked to record
Method on the questionnaire if any of the following had
concerned them before commencing orthodontic
To gain further information on this topic a survey
was made of patients and their respective parents treatment:
attending the Orthodontic Department at the Leeds (1) Presence of irregular alignment of the upper
Dental Hospital. Questionnaires were distributed anterior teeth.
and collected in accordance with the guidelines (2) Presence of spacing between the upper anterior
recommended by Moser and Kalton (1979). The teeth.
replies were anonymous to encourage unbiased (3) Prominent upper incisors.
responses from the subjects. Of the 240 question- (4) Prominent lower incisors.
naires distributed 218 were returned, but owing to The answers given were analyzed with respect to the
the late return of 11 of these only 207 were included objective aesthetic evaluation recorded.
in the data analysis giving a percentage return of
86 per cent. This is well above the level needed to Results
make the data analysis valid. Patients were only
included in the survey if they were aged less than The patients were all asked to assess the appearance
eighteen years, attended school full time and were of their own teeth, prior to orthodontic treatment,
either undergoing active appliance therapy or in full and to compare it with that of their class mates
time retention. (Table 1). Although 65 per cent of the respondents

88
 An Investigation into some of the Factors Influencing the' Desire for Orthodontic Treatment

indicated dissatisfaction, there were still 35 per cent TABLE 3

of patients wearing appliances who were satisfied The distribution of patients expreuing concern
with their dental appearance prior to treatment. with the presence of crowding/rotation in the
Seventy-one per cent of the respondents felt their upper labial segment
dental appearance had been below average. In both Age in years at start of treatment
instances there was a slight insignificant sex dif-
ference in the results (P ~ Q-20). 5-10 11-12 13-16 Total
The relationship between the patients' subjective No.% No.% No.% No.%
assessments of their own dental appearance and Boys 7(70) 6(50) 7(50)* 20(56)
their recorded levels of satisfaction prior to treat- Base 10 12 14 36
ment are shown in Table 2 which reveals that this Girls 9(50) 17(59) 23(85)* 49(66)
relationship does not correlate in the expected Base 18 29 27 74
manner for the patients in Groups 'B' and 'C'. This Total 16(57) 23(55) 30(73) 69(63)
will be discussed later. (Boys and girls)
The relationship between malocclusions, recorded Base 28 42 41 110
by the author and cause(s) of the patients concern
were analyzed with respect to the following: • P EO; 0·02.
The bases refer to the distribution of patients possessing
a. Concern Expressed by the Presence of Crowding/ crowdingjrotation.
Rotations
The presence of either crowding or rotations in
the upper labial segment caused concern to 63 concern affected girls more than boys, particu-
per cent of patients who had this irregularity. The larly in the oldest age group (P ~ Q-02). The
influence of age was less clear for boys being
unchanged from 11 years old (Table 3).
TABLE 1 b. Concern Expressed by the Presence of Spacing
Distribution of patients (a) Indicating Concern about spacing in the upper labial seg-
dissatisfaction with their dental appearance prior
to treatment and (b) assessing their dental ment was less than for crowding or rotations;
appearance to be below average when compared only one-third of those with spacing expressed
with their classmates concern (Table 4). A slight sex difference was
Boys Glrla
noted (P ~ Q-05), more girls being concerned
Total
than boys especially in the oldest age group.
No. % No. o/o No. %

(a) Diasatisfied 42 (58) 92 (68) 134 (66)

(b) Below average 47 (66) 100 (76) 147 (71)
appearance TABLE4
Baaa Total 72 136 207 The distribution of patients expressing concern
with the presence of spacing in the upper labial
segment

Age In years at start of treatment

TABLE2 6-10 11-12 13-18 Total

No.% No.% No.% No.%
Correlation between patient satisfaction and
subjective assessment of dental appearance when Boys 2(22) 1 (17) 2(25) 6(22)*
compared with classmates Base 9 6 8 23
No. o/o Girls 4(31) 5(41) 12(67) 21 (49)*
Base 13 12 18 43
A. Below average appeerance and diasatlsfied 119 (57) Total 6(27) 6(32) 14(54) 26(39)
B. Below average appearance and aatilfied 29 (14)
C. Above average appearance and dinatisfied 14 (7)
(Boys and girls)
D. Above average appearance and aatiafied 46 (22) Base 22 18 26 66
Baaa 207 100"/.
• p" (}05.
A. no appreciable aax difference was noted the above data for The bases refer to the distribution of patients possessing
boys and girls - e combined. spacing.

89
 Mary B. E. Gosney

c. The Relative Influence of Overjets, Crowding/ did not associate with their reversed overjet. In
Rotations and Spacing as Sources of Concern to the reversed overjet group all patients who had
Patients expressed dissatisfaction mentioned protrusion
The level of satisfaction was found to be inversely of the lower anterior teeth as the reason.
proportional to the overjet for values greater Although dissatisfaction with dental appearance
than 1 mm (Fig. 1). Surprisingly the highest level was shown to be proportional to the degree of
of satisfaction with dental appearance was re- overjet, the influence which other irregularities
corded in the 16 patients possessing a reverse (such as crowding, rotations or spacing) may have
overjet (i.e. < 0 mm). However, these patients was further investigated. (For the purpose of this
may have been dissatisfied with facial aesthetics investigation an overjet of 4 mm was defined as the
caused by mandibular prognathism which they upper limit of 'normality' to correspond with a
60 Class I incisor relationship.)
Table 5 showed that just over half of those with an
overjet in the range of 5-7 mm (inclusive) mentioned
50 r- this as a source of concern. Girls were slightly more
concerned than boys, but the difference was not
r-- significant. Crowding or rotations concerned 70 per
40 ..-- cent of those patients in whom this was present, and
approximately half of the patients with spacing
r-- mentioned this as a worry. Only two patients did
,.-- not register any concern with their dental appear-
ance and these were both boys. It would seem,
therefore, that other anomalies, in particular crowd-
20 ing or rotation are more likely to cause dissatisfac-
tion than a modest overjet of 5-7 mm especially in
boys.
10 As one would expect, a large percentage (81 per
cent) of patients with overjets of at least 8 mm
_[] referred to this as a source of concern, both sexes
being equally affected. However, the remaining 12
<0 0,-1 2-.4 5-7 8-10 >10
(16) (29) (61) (37) (47) (17) patients (19 per cent) were apparently unconcerned
Overjet (mm) about an appreciably increased overjet. Only two
Fig. 1. This shows the percentage of patients in each
registered no concern at all, the remaining 10
overjet range expressing satisfaction with their dental patients being concerned about other irregularities.
appearance. (The numbers in brackets refer to the base The majority of patients (67 per cent) in whom
total of patients in each overjet group). crowding or rotations were present mentioned this

TABLE 5
Distribution of concern expressed for crowding/rotation, spacing and maxillary overjet by patients
possessing overjets of 6 mm and over

Feature mentioned as c.aualng concern Not concerned

Increased overjet Crowding/rotation Spacing

Overjet (mm) Boys Girls Total Boya Girls Total Boys Girls Total Boys Girls Total
No.% No.% No.% No.% No.% No.% No.% No. o/o No. o/o No. o/o No.% No. o/o

6-7 mm 6(42) 16(60) 20(64) 6(71) 9(69) 14(70) 2(67) 6(42) 7(47) 2(17) 0(0) 2(5)
Base 12 25 37 7 13 20 3 12 15 12 25 37
;;.8mm 24(80) 28(82) 62(81) 5(71) 5(63) 10(67) 3(15) 8(42) 11 (28) 1(3) 1 (3) 2(3)
Base 30 34 64 7 8 16 20 19 39 30 34 64

The bases refer to the distribution of the anomalies i.e. crowding/rotation, spacing, increased overjet actually present. (As crowding/
rotation and spacing co·existed in a few cases the bases, do not add up to the same total as the actual number of patients.)

90
 An Investigation into some of the Factors Influencing the Desire for Orthodontic Treatment

TABLE6 100
Distribution of persons involved in initially 90
recognizing the dental defect (as remembered by r--
the patient) 80
Penon recognizing Total G) 70
abnormality Boys Girls (Boys and girls) J
No.% No.% No.% B so
r--
Patient (Child) 10(12)* 42(27)* 52(22) ~50
Mother 30(37) 53(33) 83(35)
Father 9(11) 7(5) 16(6) 40 .--
Dentist 31 (38) 48(30) 79(33)
Other 2(2) 8(5) 10(4) 30 r- r-
Base 82(100) 158(100) 240(100)
Nil response 3 3 6 20 r-

• p "(}02. 10

<0 Q-1 2-4 5-7 8-10 >10

as a sQurce of concern but spacing only worried Overjet (mm)
28 per cent of those possessing it More girls were Fig. 2. This shows the percentage of patients in each
concerned about the presence of spacing than boys, overjet range who were teased about their dental
but this was not significant (P = Q-0823 using the appearance prior to orthodontic treatment.
Yates exact method).
In response to the question as to who first noticed
the presence of their dental anomaly, it is interesting The prevalence of teasing prior to treatment
to note that it was the patient in only 22 per cent of repo~ted by patie~ts and its relationship to their
cases (Table 6). In some cases more than one person oveiJets was mvesttgated. It was found that 42 per
was mentioned and because of this the Table shows cent of respondents had been teased and as expected
a total number involved, which is greater than the the greatest prevalence of teasing occurred in those
number of patients~ Slightly more girls initially individuals with overjets in excess of 10 mm (Fig. 2).
recognized the existence of an irregularity than boys However, teasing was not directly proportional to
s~ of overjet. Table 7 shows the overjet ranges
(P ~ 0·02). Collectively, parents accounted for
41 per cent of first recognition (usually Mother) wtth respect to the co-existence of other visible
while the general dental practitioner was remem~ anomalies (i.e. crowding/rotation or spacing), in
bered as being involved in one third of cases. order to assess any influence from these on the
findings. Although the numbers involved are small
the trend which emerges supports the view that th~
TABLE 7 size of an overjet is an important factor in deter-
The relationship between teasing and overjet taking mining the likelihood of a person being teased.
Into account the presence of superimposed However, the effect of other irregularities in the
crowding/rotation or spacing presence of an increased overjet not exceeding
No other Crowding/ Spacing 8 mm, appeared to modify the importance which the
Overjet (mm) anomaly rotation overjet itself played in provoking teasing. The data
also suggest that even for larger overjets (i.e. in
<6mm 1 (26) 23(27) 7(39) excess of 8 mm), the presence of superimposed
Base 4 86 18
1(26) 13(66) 7(47)
spacing may. increase external perception and,
5-7 mm
Base 4 20 16 therefore teasmg.
8-10 mm 4(40) 6(45) 12(44) To assess the relative contribution which the
Base 10 11 27 major factors have on motivation patients were
>10mm 2(67) 2(67) 12(100) asked to rank the following in order of the impor-
Base 3 3 12
Nil responses- 2
tance they had played in their decisions to undergo
orthodontic treatment:
(As crowding/rotation and spacing co-existed in a few (a) Others at school were wearing an appliance.
cases the bases, which refer to the number of instances In
(b) Their dentist recommended it in the interests of
each overjet range when spacing or crowding/rotation
occurred, do not add up to the same total as the actual dental health.
number of patients.) (c) To improve the appearance of their teeth.

91
Mary B. E. Gosney

TABLE B
The ranking order of importance given to the factors which influenced the patients to accept
orthodontic treatment

Influencing factors Ranking order of importance (frequency of responses given)

Nil Median Ranking

1st 2nd 3rd 4th 5th response value order

Total
A Others wearing appliances 0 6 14 14 123 50 78 5
B Dentist's advice 102 78 8 11 0 8 99 1
C Improve dental appearance 95 73 13 11 3 12 97 1
D Mother's wishes 15 36 109 18 1 28 89 3
E Father's wishes 7 11 29 101 11 48 79 4

(d) Mother wanted the child to have treatment. The parents were asked to indicate who had
(e) Father wanted the child to have treatment. suggested their child have orthodontic treatment
(Table 9). It was suggested most frequently by
The data obtained are shown in Table 8. In order the dentist, with the parents (usually the mother)
to ascertain the overall order of choice the accounting for 23 per cent, and the child 7 per cent.
median value for each of the above factors was As can be seen from Table 9 these findings are
obtained. The ranking position at which the median almost identical to those obtained by Shaw et al.
value comes in the sequence gives the ranking order (1979) in Cardiff, but contrast significantly with
for that factor. On analysis the ranking order was those of Dorsey and Korabik (1977) who, in their
found to be: St Louis, USA study, showed most of the sugges-
lst =(b) Dentist's advice. tions for treatment were proposed by the patient's
2nd =(c) To improve the appearance of the teeth. mother. The data were also analyzed for social class
but no systematic pattern emerged.
3rd =(d) Mother's wishes. The parents were further asked in a separate
4th =(e) Father's wishes. question whether they thought a good dental ap-
5th = (a) Others wearing appliances at school. pearance was more important or equally important
for boys or girls. They were of the unanimous
The data were analyzed to assess the influence of sex opinion that a good dental appearance was equally
and social class, but no significant differences were important for boys and girls irrespective of the sex of
found. their own child who was under treatment.

TABLE 9 Discussion
Distribution of persons involved in suggesting
orthodontic treatment (figures for Cardiff and
From this investigation it would appear that crowd-
St Louis are shown for comparison) ing and rotations and, to a lesser extent spacing,
usually caused concern to the patients and even the
St Louis simultaneous presence of a large overjet did not
Person suggesting Leeds Cardiff USA conceal the effect of these irregularities as sources of
treatment No.% % %
concern. This was demonstrated by the apparent
Child (patient) 15(7) (5) (4) lack of anxiety shown by 19 per cent of patients to
Dentist 149(68) (70) (55) overjets of at least 8 mm, 16 per cent of these being
Mother 43(20)• (21) (35)* concerned instead about the other anomalies. If as
Father 8(3) (5) (5)
Other 4(2)
Horowitz et al. (1971) and lngervall and Hedegard
(1974) have indicated the perception of irregular
Base Total 219(100) 200 299
alignment and spacing is greater than the percep-
p ~ 0·001.
tion of overjets it seems reasonable to conclude that
Base refers to the total number of persons involved in a moderately increased overjet in isolation is not as
suggesting treatment. great a source of dissatisfaction as one might expect.

92
 An Investigation into some of the Factors Influencing the Desire for Orthodontic Treatment
Thus, in making orthodontic assessments, attention
should be given to ascertain fully the particular
occlusal and aesthetic deviations which are causing
concern to the patient. Assumptions based purely
on the presenting occlusal condition should be
avoided.
The relationship between the patient's subjective
assessment and level of satisfaction with dental
appearance is shown in Table 2.
As expected, the majority of the patients came
into Category 'A' being dissatisfied with their ap-
pearance, and their motivation for treatment may
be regarded as self-evident. The patients in Cate-
gory 'D' assessed their dental appearance to be
above average and were, as one would therefore
expect, satisfied even though their subjective assess-
ment of_appearance may not have coincided with an
objective evaluation. However, the motivation for
treatment in these patients is less evident and factors
other than aesthetics appear to be operating to an
appreciable extent. Of interest are the patients in
Categories 'B' and 'C' where the relationship be-
tween subjective assessment of dental appearance
and level of satisfaction does not correlate in the
expected manner. Category 'B' consisted of an
appreciable 14 per cent of the respondents who were
at least fairly satisfied with their dental appearance
even though they rated themselves below average
for dental aesthetics. In total contrast are the rather
more fastidious patients belonging to Category 'C'
in whom a feeling of dissatisfaction prevailed despite
a subjective assessment of possessing an 'above
average' dental appearance.
The above findings are in accord with the results
obtained by Shaw (1981) from a study in which a
general sample of school children were interviewed.
He found that 48 per cent of those children who
possessed moderate to severe irregularities were
satisfied, while others having minor or no visible
irregularities were dissatisfied. Dissatisfaction with
one's dental appearance, regardless of an objective
aesthetic evaluation, may manifest itself as a reti-
cence to talk or smile without inhibition, and
thereby adversely affect social relationships.
The results also showed that the desire to have a
better dental appearance was most important in the
patients' motivation for orthodontic treatment. The
equally high level of importance accorded to the
advice of the dentist does emphasize however,
the level of professional trust that is placed in the
dentist by the child and parents (although the
importance of this factor may have been artificially
elevated because of the dental background of the
survey). Parental influence was not indicated by
most patients to be a major factor in motivation to
have treatment, but greater indirect parental in-
fluence may well have been operating at a sub-
liminal level. It is of interest to note that initial
recognition of the dental anomaly by the parents
was greater than was their involvement in the
suggestion for treatment (Tables 6 and 9). This
supports the findings of Todd (1973) and Luffing-
ham and Campbell (1976) who showed that the
assessment of orthodontic conditions by parents
was often at variance with professional judgements.
In their studies even when orthodontic irregularities
were recognized by the parents, many of them
thought the severity of the irregularity did not
warrant specialist treatment.
In conclusion, the literature has implied that for
the majority of patients the primary psychological
impact of a malocclusion does not result from the
response of others to the defect but from the
individual's own reaction to the anomaly. The
present findings support this; less than half of the
patients questioned had been teased about their
malocclusions prior to treatment. Furthermore,
only 22 per cent of the patients remembered them-
selves as being involved in its initial recognition. It is
thus quite probable that once a child has been made
aware of a defect by someone such as a parent or
dentist, attention is focussed increasingly on it and
concern about the defect develops. Thus dental
practitioners should deliver professional guidance
concerning dental aesthetics, but should not im-
press their aesthetic values on a patient.
If one concludes that the major reason for the
provision of orthodontic treatment is for aesthetic
rather than functional considerations, the question
arises as to whether such treatment provides a
service for a previously existing need or whether the
service itself creates the demand. Certainly the
provision of orthodontic treatment has increased
markedly in this country over the last few decades in
parallel with an increase in the level of expectation
for dental health and longevity expressed by many
sections of society (Lewis, 1982). The once accept-
able provision of dentures in early adulthood has
been replaced by the desire to maintain a pleasing
natural dentition for life, and the increased demand
for orthodontic treatment has arisen most probably
as a consequence of this.
Acknowledgements
I am most grateful to Mr J. F. Gravely, Senior
Lecturer in Orthodontics, University of Leeds, for
93
Mary B. E. Gosney
his advice and guidance during the investigation
and to Mrs V. A. Lavington and Mrs J. Seviour for
their secretarial assistance.
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