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 Table of Contents  
Year : 2019  |  Volume : 53  |  Issue : 1  |  Page : 14-20

Does malocclusion affect Adolescents' social acceptance?

Assist. Prof., Department of Orthodontics, Faculty of Dentistry, King Abdul Aziz University, Jeddah, Saudi Arabia

Date of Submission07-Mar-2018
Date of Acceptance14-Aug-2019
Date of Web Publication5-Feb-2019

Correspondence Address:
Dr. Fadia M Al-Hummayani
P.O. Box 80464, Jeddah 21589
Saudi Arabia
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jios.jios_29_18

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Objectives: The aim of this study was to evaluate the social impact and self-perception of malocclusion among adolescents and to investigate whether types and severity of malocclusion have any effect on adolescents' social acceptance. Methodology: The sample size was 886 males and females living in Jeddah city, Saudi Arabia, chosen from middle and high schools' students, with ages ranging from 12 to 19 years. After completion of the questionnaire to assess social impact, all participants were examined using Index of Orthodontic Treatment Need (IOTN), Dental Health Component, and Aesthetic Component. Results: The results showed that there was a highly significant difference between the means of both social impact and self-perceived need scores according to gender and according to the severity of treatment need as assessed by the examiner using IOTN. Malocclusion has a negative effect on social acceptance. Anterior spacing, anterior open bite, increased overjet, and crowding–in this order–have the most negative impacts on adolescents' social acceptance. Conclusions: Social acceptance is negatively affected by the severity of malocclusion. Spacing, open bite, increased overjet, and crowding have the most negative impacts on adolescents' social acceptance.

Keywords: Adolescent, malocclusion, social impact

How to cite this article:
Al-Hummayani FM, Taibah SM. Does malocclusion affect Adolescents' social acceptance?. J Indian Orthod Soc 2019;53:14-20

How to cite this URL:
Al-Hummayani FM, Taibah SM. Does malocclusion affect Adolescents' social acceptance?. J Indian Orthod Soc [serial online] 2019 [cited 2019 Jun 16];53:14-20. Available from: http://www.jios.in/text.asp?2019/53/1/14/251552

  Introduction Top

Malocclusion is a highly prevalent oral condition worldwide.[1],[2] In a study by Haralur et al. on the prevalence of malocclusion in Saudi Arabia, they concluded that 42.8% of their study population had malocclusion ranging from specific to handicapping malocclusion.[3]

Malocclusion usually leads to esthetic and functional impairment; thus, it might lead to psychological, social, intellectual, and peer acceptance consequences, especially in children and adolescents.[4],[5],[6] The literature shows that most people focus on an individual's eyes and smile. Consequently, having an attractive smile is a large part of perceived beauty and thus social acceptance.[5] Compromised esthetic and functional limitations of malocclusion cause great social impact on building good, stable relationships.[7],[8] Therefore, seeking orthodontic treatment is mainly initiated by people who are concerned about their appearance.[7],[9],[10]

The adolescent period is a critical time of growth that involves anatomical, physical, and most importantly, psychological changes that might affect the person all his/her life. Therefore, adolescents are usually apprehensive about their body image, which is an important part of psychological well-being, social acceptance, and educational achievement.[7],[11],[12] The American Psychology Association highlighted the importance to the adolescent of acceptance by his or her peers; peer rejection causes several negative behaviors and an isolated social life.[12],[13] Peer rejection causes several negative behaviors and an isolated social life.[13] Hence, this age group is considered an appropriate one for studying the social impact caused by esthetic perceptions and malocclusion.

Occlusal indices are used to measure the degree of malocclusion such as the Index of Orthodontic Treatment Need (IOTN).[7] Brook and Shaw designed IOTN, and it has gained international acceptance as an orthodontic assessment tool.[2],[14] It is composed of two parts: the dental health component (DHC), which defines the need of treatment according to features and severity of malocclusion, and the Aesthetic component (AC), which records the esthetic malocclusion.[6],[14]

Subjective aspect of the patient's perception of malocclusion should be considered determining the orthodontic treatment needs.[7],[15] Several studies believe that the patient's perception is an important indicator of treatment needs.[2],[16],[17],[18] Thus, the World Health Organization has suggested the inclusion of quality-of-life measurements and psychosocial tests in clinical studies[2],[19] and encourages using them as an important additional diagnostic tool.[2],[20]

The importance of the present study lies in understanding the long-term influence of malocclusion on quality of life and its psychosocial implications. This will improve clinician–patient communication and increase patient understanding and compliance.

The aim of this study was to:

  1. Evaluate the social impact and self-perception of malocclusion among adolescents
  2. Investigate whether types and severity of malocclusion have any effect on adolescents' social acceptance
  3. Examine the effect of demographic factors on the social impact and self-perception of malocclusion in adolescents.

  Methodology Top


This school-based cross-sectional study was conducted in Jeddah at the western region of the Kingdom of Saudi Arabia. Nine hundred and seventy-five adolescents were invited to participate in the present study. Participants were chosen from middle and high schools' students ranging in age from 12 to 15 years and >15–19 years, respectively, and from both public and private schools. Students undergoing orthodontic treatment and those who have craniofacial anomaly were excluded from the study. These criteria resulted in a sample size of 886 adolescents.

Informed consents were obtained from both parents/guardians and students. After obtaining both consents, students were given a paper-based questionnaire to complete.

Ethical approval for this study was obtained from the Research Ethics Committee at the Dental School of King Abdulaziz University in Jeddah #040/13.


The questionnaire was designed with two parts. Part one consisted of demographic data information (age, gender, level of education, and type of schooling). Part two consisted of seven questions. Question one was related to the participant's perceived need for orthodontic treatment; question two was related to the participant's satisfaction with his or her dental appearance; questions 3, 4, 5, 6, and 7 asked about the social impact of malocclusion [Table 1]. Each question contained a 4-point Likert scale, ranging from 1, “definitely,” ranking down to 4, “not at all.” This questionnaire was inspired by the social acceptance questionnaire of Mandall et al's study[21] and Badran's study.[16] The sum of the scores described the self-perceived social impact of malocclusion on the participant.
Table 1: Need for treatment, satisfaction with dental appearance and social impact of malocclusion

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The participant's native language was not English; therefore, forward–backward translation of the questionnaire was done in a licensed translation office. The reliability and validity of the questionnaire were tested using Cronbach's alpha and Pearson' correlation analyses on forty questionnaires.

Malocclusion assessment

After completion of the questionnaire, all participants were examined by the authors under natural daylight, using the IOTN DHC for categorizing the participants' condition, according to severity of the malocclusion, into five grades: Grade 1: no treatment need; Grade 2: mild/little need; Grade 3: moderate need; Grade 4: severe need; and Grade 5: extreme need of treatment.

The main type of anterior malocclusion was also registered using the following parameters: overjet, anterior overbite, anterior cross bite, anterior open bite, and crowding or spacing.

The AC of the IOTN was then used to measure the student's self-perception of his or her esthetics. The AC is composed of ten photographs of different levels of anterior malocclusion severity and attractiveness, starting from ideal anterior dental appearance or the most attractive at Grade 1, proceeding to a severe anterior malocclusion or the least attractive at Grade 10. Each participant was shown the photographs in the AC. The student was asked to select the photograph that represented his or her dental appearance; subsequently, each examiner also chose the photograph that represented the student's dental appearance.

The examiners were calibrated prior to examining the participants to minimize inter- and intra-examiner errors.

Statistical methodology

The statistical analyses were performed using the Statistical Package for the Social Sciences, version 20 (SPSS Inc., Chicago, IL, USA).

  1. The frequency and percentage for each category of data were calculated as part of the descriptive statistical analysis
  2. Independent sample t-test and ANOVA test were used to compare means in two independent groups and more than two groups, respectively
  3. Spearman's correlation coefficient analysis was used to test the association between social impact, self-perception, dental appearance, and satisfaction
  4. Step-wise linear regression was conducted to assess the relative influence of independent variables on the dependent variable. The probability value for independent variables for removal was 0.10.

  Results Top

Out of the 886 students sampled, 670 responses (76%) were included in the analysis and 216 responses were excluded due to incomplete responses. The sample was composed of 280 (41.8%) males and 390 (58.2%) females, with mean age of 15.33 years and standard deviation of 1.8; the minimum age was 12 years and maximum age was 19 years. Three hundred and seventy (55.2%) students attended private schools and 300 (44.8%) attended public schools; 307 (45.8%) were middle school students, whereas 363 (54.2%) were high school students.

Reliability and intra-examiner reproducibility

The reliability of the questionnaire was tested using Cronbach's alpha analysis on forty questionnaires. It showed a coefficient of 0.671 for the questionnaire. Intra-examiner kappa value for the DHC and AC was 0.85, which indicated good intra-examiner reproducibility.

Validity of the questionnaire

Pearson's correlation test was used to determine the construct validity of the questionnaire, showing (r) values ranging between 0.4 and 0.5, indicating moderate validity. However, the correlation values of all variables were highly significant (0.000) due to the large sample size.

Demographic variables versus social impact and self-perceived need scores

[Table 2] shows that there was no statistically significant difference in any of the demographic variables with the social impact and self-perceived need scores, except for gender with the mean of self-perceived need score, showing a highly significant difference between females and males (P < 0.001).
Table 2: Demographic difference of perceived social impact and self-perceived need scores

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Malocclusion severity versus social impact and self-perceived need scores

There was a highly significant statistical difference (P < 0.001) between the means of both social impact and self-perceived need scores according to the severity of treatment need as assessed by the examiner using IOTN [Table 3].
Table 3: The influence of malocclusion severity on social impact and self-perceived scores

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Anterior malocclusion types versus social impact and self-perceived need scores

[Table 4] shows that the lowest mean score of social impact was found in students with anterior spacing (16.46; standard deviation [SD] 2.98), followed by anterior open bite (16.77; SD 2.18), increased overjet (16.91; SD 2.11), and crowding (17.15; SD 2.28). Self-perceived need scores showed that participants with multiple malocclusions have the highest mean (4.14; SD 2.30) followed by participants with spacing and crowding with mean scores of 3.25 (SD 1.78) and 3.33 (SD 2.12), respectively. ANOVA test showed a highly significant difference (P < 0.001) between the groups in both social impact and self-perceived need scores.
Table 4: The influence of different types of anterior malocclusion on social impact and self-perceived need

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Spearman's correlation analysis

Spearman's correlation analysis showed a statistically significant correlation between the perceived social impact of malocclusion, self-perceived dental esthetic, perceived treatment needs, and normative treatment needs, with weak-to-moderate coefficients (0.335, 0.535, and 0.569), respectively.

Social impact, self-perceived needs, and satisfaction with appearance

Multiple regression model analysis was done with the social impact as dependent variable and gender, level of education, dissatisfaction with dental appearance, smiling, student and examiner AC, and IOTN as independent variables; 25.2% of the variables could be explained by the model, with dissatisfaction with dental appearance, smiling, and student AC (self-perceived) having highly significant statistical relationship (P < 0.001) and examiner AC having slight statistical significance (P = 0.048). On the other hand, when a multiple regression model was done with the self-perceived need as dependent variable and gender, perceived need for treatment, dissatisfaction with dental appearance, smiling, and esthetic component for the examiner as independent variables, 37.2% of the variables could be explained by the model, with gender, perceived need for treatment, smiling, and examiner AC having highly significant statistical relationship (P < 0.001) [Table 5].
Table 5: Stepwise multiple regression models of the independent variables on social impact and self-perceived need

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  Discussion Top

In the present study, we used the AC of the IOTN to measure the student's perception of his or her dental esthetic; this index was described by Brook and Shaw in 1989, and it has been gaining wide recognition. Hassan,[14] Bellot-Arcís et al.,[22] and Trivedi et al.[13] have proven the validity of this index and agreed that the AC index is an effective tool for measuring esthetic treatment need. The reliability of the questionnaire in the present study was 0.671; Bowling's recommendation for an acceptable alpha is between 0.7 and 0.9. However, smaller alphas are acceptable with smaller subscales.[23]

One of the statistically significant findings of this study was that females were more critical in evaluating their dental esthetic appearance than males. Thus, females see themselves as less attractive [Table 2]. This is in agreement with several studies.[5],[22],[24],[25],[26] However, other studies disagree.[1],[7],[27] The explanation of this finding is related to the wide variety of beauty perception among cultures;[28] attractive smile could be associated with high-class, intelligent people. This explains why the new generation of adolescent females in Saudi Arabia pays more attention to their esthetic appearance and has more desire for orthodontic treatment. A second explanation of this finding is that females in general are more anxious about their facial appearance and oral health than males.[7],[25],[28] Furthermore, the extensive use of social media might also contribute to this finding; more investigation is needed.

The present study reveals that the negative social impact of malocclusion has an effect on the individual. This impact increases as the severity of the malocclusion increases, in accordance with the study by Dawoodbhoy et al., which concluded that only very severe malocclusion cases will have an impact on quality of life.[27] However, de Paula Júnior et al. stated, “It is not uncommon to observe that some patients with severe malocclusions are satisfied with or indifferent to their dental esthetics, while others are very concerned about minor irregularities.”[7]

Students who felt a negative social impact from their malocclusion had a great need of orthodontic treatment, as assessed by the examiner. They were also significantly less satisfied with their dental appearance and hid their smile. Furthermore, students who perceived themselves to be in great need of orthodontic treatment and had great normative treatment need also saw themselves as unattractive and hid their smile. Although the results were statistically significant, the correlation values (residual mean square) were slightly low (25.2 and 37.1). This might lead us to question the clinical importance of the present results. However, the American Psychology Association emphasizes that adults must take adolescents' concerns about their looks seriously, regardless of how small they are, and should understand the side effects of emotional abuse and peers' rejection, which could lead to serious negative behavior such as delinquency, drug abuse, dropping out of school, and aggression.[12] Several other studies agree.[1],[6],[7],[16],[22],[26],[29] Based on these findings, orthodontists must not only concentrate on functional and oral health improvement, but also consider psychological and social impairment from malocclusion.

The results of this study have revealed that dentoalveolar spacing, anterior open bite, increased overjet, and crowding–in that order–had the most negative social impacts on adolescents. Almost similar results were reported in other studies but with minor changes in the order; this could be related to several factors. First, the other studies might be using different measures and indices to evaluate malocclusion and self-perception. Second, differences in participant's age could be a factor. It is well documented that esthetic perception changes with age.[1],[24],[30],[31] A third factor could be related to different cultures and social norms between countries that may influence esthetic perception. Finally, high frequency of certain malocclusions within some ethnic groups makes this type of malocclusion perceived as normal.[1],[5],[32],[33],[34]

The authors think that the negative impact of dentoalveolar spacing and anterior open bite cases could be related to the alteration in speech as a result of these types of malocclusion. Peres et al.[24] established that speech capability is associated with anterior malocclusion, and Sahad Mde et al.[35] stated, “There was a significant relationship between open bite and anterior lisping.”

Dahong et al. think that an increase of overjet might influence the person's appearance, resulting in a protrusive profile; thus, it might have an impact on the psychosocial health of the person.[36] Pithon et al. concluded that crowding is the type of malocclusion that leads to the most unattractive smile[4] and thus, the highest level of rejection. This has a negative social influence, as concluded by Rossini et al.[37]

Johal et al. revealed in their study that malocclusion also has a negative influence on parents and family members, as much as it influences the children themselves.[34] We can say that all these negative effects of malocclusion on children and their families are augmented by the overuse of multimedia and social media and, as we know, the term “Hollywood smile” is an expression known worldwide, which puts the adolescents under more stress from their malocclusion. Further investigation is needed.

One of the limitations of the present study is that using AC of the IOTN does not represent all types of malocclusions such as cross bites, open bites, and Class III. Another limitation is that the profile assessment is not included in the present study, and it is well known that profile attractiveness plays a big role in the facial beauty that might affect social acceptance, and hence further studies are needed.

Clinical implications

Orthodontists must not only concentrate on the functional and oral health improvement, but also consider the psychological and social impairment of malocclusion.

  Conclusions Top

  1. Malocclusion has a negative social impact. This impact increases with malocclusion severity
  2. Dentoalveolar spacing, open bite, increased overjet, and crowding–in this order–have the most negative impacts on adolescent social acceptance
  3. The tested demographic data such as age, gender, level of education, and type of schooling showed no statistically significant difference on social impact. However, gender shows highly significant difference between females and males (P < 0.001) on self-perception of malocclusion.


The authors would like to thank Professor Hebbal Mamata, Department of Preventive Dentistry at the Faculty of Dentistry, Princess Nourah bint Abdulrahman University, for her valuable contribution.

Financial support and sponsorship

This was a self-funded study.

Conflicts of interest

There are no conflicts of interest.

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  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]


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