ORIGINAL ARTICLE

Expectations of treatment and satisfaction withdentofacial appearance in patients applying fororthodontic treatment

Naomi A. van Wezel,a Annemieke Bos,b and Charlotte Prahlb

Amsterdam, The Netherlands

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Introduction:Satisfaction with dentofacial appearance and expectations of orthodontic treatment have beenanalyzed in many studies. In 2002, in a study in The Netherlands, significant correlations were found be-tween dental satisfaction and orthodontic treatment expectations. Satisfaction significantly decreased withincreasing age. The aim of this study was to compare the satisfaction and expectations of current patientswith the results of a study 10 years ago. Methods: A questionnaire about dentofacial satisfaction and a ques-tionnaire about the expectations of orthodontic treatment were completed by 146 subjects. Themean scores inthe present study were compared with the mean scores 10 years ago. Results: The subjects in the presentstudy were more satisfied with their dental appearance. Differences in expectations were found on the sub-scales of general well-being and self-image. As in the study in 2002, no significant correlations were foundbetween sex, satisfaction, and expectations of orthodontic treatment. Dentofacial satisfaction predictsexpectations about orthodontic treatment, especially in the group of subjects aged 17 years and above.Conclusions: The subjects in this study had greater expectations of orthodontic treatment about generalwell-being and were more satisfied with their dental appearance than were the subjects studied 10 yearsago. (Am J Orthod Dentofacial Orthop 2015;147:698-703)

You never get a second chance to make a firstimpression. In verbal and nonverbal communica-tion, the face matters. The advantages of beauty

seem to be true, at least at first meeting. Facial attrac-tiveness is positively associated with high school marks,good work performance, positive peer relations, socialacceptance, high social status, positive body image,and good self-concept. It has also been proven that amalocclusion can have a negative effect on the qualityof life.1-9

Tooth color, missing teeth, and poor tooth align-ment are the most common reasons for dissatisfactionwith dentofacial appearance.10-12 It is therefore not

the Department of Orthodontics, Academic Centre for Dentistry, Universitysterdam and Free University, Amsterdam, The Netherlands.odontist.tant professor.thors have completed and submitted the ICMJE Form for Disclosure of Po-l Conflicts of Interest, and none were reported.ss correspondence to: Naomi A. van Wezel, Department of Orthodontics,mic Centre of Dentistry, Gustav Mahlerlaan 3004, 1081 LA Amsterdam,etherlands; e-mail, n.v.wezel@acta.nl.itted, February 2014; revised and accepted, January 2015.5406/$36.00ight � 2015 by the American Association of Orthodontists./dx.doi.org/10.1016/j.ajodo.2015.01.024

surprising that people seek esthetic dental andorthodontic care.11-13 Inconsistent results have beenfound regarding the association between dentofacialsatisfaction, age, and sex.2,10,14 In some studies, nosex differences were found regarding dentofacialsatisfaction and treatment expectations,2 but otherstudies showed that female subjects were less satisfiedthan were male subjects.10,15

However, it seems that dentofacial satisfaction issignificantly correlated with expectations of orthodonticpatients about general well-being, improvement of self-image, and future dental health.2 Also, orthodonticpatients seem to expect improvements in esthetics andself-esteem, regardless of their sex.2,15-17

Attitudes about dental health change over time.18 Inan epidemiologic dental study in The Netherlands, morepatients were undergoing orthodontic treatment in2005 than in 1999.19 Also, a change in orthodontictreatment need was found. The question is whetherthese findings are related to current dentofacial satisfac-tion and expectations of orthodontic patients at the startof treatment.

In this study, we replicated the study by Bos et al2 andcompared our results with those results. Because ofcontroversy about the impact of malocclusion on

van Wezel, Bos, and Prahl 699

dentofacial satisfaction and treatment expectations inthe orthodontic literature, we examined the effect ofmalocclusion on dentofacial satisfaction and treatmentexpectations as well.20-22

Based on the results of previous studies, femalepatients were expected to be less satisfied with their den-tofacial appearance than male patients.10,14 Based onthe results of Bos et al,2 younger subjects were assumedto be more satisfied with their dentofacial appearancethan older subjects. Furthermore, significant correla-tions between dentofacial satisfaction and treatmentexpectations were expected. We explored whether den-tofacial satisfaction and orthodontic treatment expecta-tions have changed over time. Finally, based on theresults of Zhang el,20 we expected that malocclusionwould have no effect on dentofacial satisfaction andtreatment expectations.

MATERIAL AND METHODS

From November 2011 to June 2012, we sent 2 ques-tionnaires to every person applying for orthodontictreatment at the Academic Centre of Dentistry Amster-dam in The Netherlands. The first questionnaireincluded 16 items about satisfaction with facial appear-ance before orthodontic treatment to be scored on a5-point response scale (from “I am very unsatisfied”to “I am very satisfied”). It was a modification of thebody-cathexis scale introduced by Secord and Jour-ard23 in 1953 and was further developed in the1980s. It gives an assessment of perceived dentofacialappearance; a high score shows greater satisfactionwith the dentofacial body part being measured.24-28

The second questionnaire included 23 items aboutexpectations of orthodontic treatment to be scoredon a 7-point response scale (from “worse” to “muchbetter”). It was initially developed for patients undergo-ing orthognathic surgery and was adjusted for ortho-dontic patients. It measures long-term expectationsof orthodontic treatment.26,29,30

The same subscales were used as in the study by Boset al.2 The questionnaire about satisfaction with facialappearance was divided into 2 subscales (facial satisfac-tion and dental satisfaction). The questionnaire aboutexpectations of orthodontic treatment was divided into4 subscales (general well-being, self-image, oral func-tion, and future dental health).

The questionnaires were sent to 220 personsapplying for orthodontic treatment at the AcademicCentre of Dentistry in Amsterdam; none had visitedthe orthodontic department before. To this type of so-cial science research, the Dutch Medical Research onHumans Act was not applicable. The questionnaires

American Journal of Orthodontics and Dentofacial Orthoped

were returned by 146 subjects (53 male, 93 female),resulting in a response rate of 67%. There were nosignificant differences in age and sex between re-sponding and nonresponding persons. Subjects withmore than 3 missing responses (n 5 10) wereexcluded from the analysis. There were no significantdifferences in age and sex between subjectswho completed the questionnaire and those who didnot.

Subjects older than 60 years (n 5 1) and youngerthan 8 years (n 5 1) were excluded from the study.The mean age of the remaining 134 subjects was 19.6years (SD, 13.49 years; median, 13 years; age range,8-60 years). After the initial analysis, the subjects weredivided into 2 age groups, as Bos et al2 did in 2003.The first group included subjects from 8 to 16 yearsold (n 5 84; 35 boys; mean age, 11.42 years; SD, 1.78years); the second group included subjects from 17 to60 years (n 5 50; 15 men; mean age, 33.36 years; SD,13.43 years). All subjects were invited for a first consul-tation. During this consultation, the subjects (n 5 123)were scored with a Class I (n 5 59), Class II (n 5 57), orClass III (n 5 7) malocclusion.

Statistical analysis

First, the internal consistencies of the scales and sub-scales were determined using the Cronbach alpha. Toanalyze the effects of sex and age on dental and facialsatisfaction and expectations of orthodontic treatment,the Mann-Whitney U test was used. Also, the meanscores of the subscales for the subjects with a Class Imalocclusion were compared with the mean scores forsubjects with a Class II malocclusion using the Mann-Whitney U test. The Spearman correlation coefficientwas calculated for satisfaction with dental and facialappearance and expectations of orthodontic treatment.Next, a multiple regression analysis was performed toestimate the effect of the initial facial and dental satis-factions on expectations of orthodontic treatment. Toanalyze changes in satisfactions and expectations overtime, the mean scores in our study were comparedwith the mean scores from the study by Bos et al2 using1-sample t tests.

RESULTS

The internal consistency in 2012 of the questionnaireon satisfaction was satisfactory. The Cronbach alpha forthe total scale was 0.93. Internal consistency values forthe 2 subscales were 0.93 and 0.52, respectively, forsatisfaction with facial appearance and dental appear-ance. The internal consistency of the questionnaire onexpectations was satisfactory as well. The Cronbach

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Table I. Correlations between expectations and satis-faction

ExpectationGeneral

well-beingSelf-image/appearance

Futuredentalhealth

Oralfunction

Age #16 yearsSatisfaction withfacial appearance

0.97 0.36 0.33 0.78

Satisfaction withdental appearance

0.64 0.11 0.69 0.13

Age $17 yearsSatisfaction withfacial appearance

0.31* 0.29 0.29 0.30*

Satisfaction withdental appearance

�0.15 �0.24 �0.14 �0.07

*P\0.05.

700 van Wezel, Bos, and Prahl

alpha for the total scale was 0.94, and the internal con-sistency values for the 4 subscales were 0.94 for generalwell-being, 0.91 for self-image, 0.83 for future dentalhealth, and 0.85 for oral function.

No significant differences on the subscales and to-tal scales were found between the male and femalesubjects for age and sex differences in 2012. However,age was significantly related to facial satisfaction(U 5 1403.500; P 5 0.004), dental satisfaction(U 5 1461.500; P 5 0.003), and expectations aboutself-image (U 5 1536; P 5 0.049). Patients youngerthan 17 years of age were more satisfied with theirfacial and dental appearances, and they had lower ex-pectations of orthodontic treatment with regard toimprovements in self-image in comparison with oldersubjects.

The group of subjects with a Class III malocclusion(n 5 7) was relatively small and was therefore excludedfrom the analysis. The scores for subjects with a Class Imalocclusion (n 5 59) were compared with the scoresfor subjects with a Class II malocclusion (n 5 57). TheMann-Whitney U test showed no significant differencesin the subscales and the total scale between subjectswith Class I and Class II malocclusions (facial satisfac-tion: U 5 1486.50, P 5 0.527; dental satisfaction:U 5 1433.00, P 5 0.163; general well-being: U 51287.50, P 5 0.295; self-image: U 5 1285.00, P 50.131; future dental health: U 5 1576.00, P 5 0.908;and oral function: U 5 1306.00, P 5 0.275).

In Table I, the Spearman correlations between thedifferent variables were analyzed for the 2 age groups.Satisfaction with facial appearance was significantlycorrelated with expectations about general well-beingand oral function only for subjects 17 years and older.No correlation was found between sex and expectationsof orthodontic treatment.

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A multiple regression analysis was used to determinewhich variables affected the expectations of orthodontictreatment for the 2 age groups. Table II shows that facialsatisfaction and dental satisfaction are significant pre-dictors for expectations about future dental health forsubjects younger than 17 years. Dental and facial satis-faction together explained 12% of the variance of thesubjects' expectations about future dental health. Dentalsatisfaction was also a significant predictor for expecta-tions about oral function for subjects younger than 17years.

Table III shows that satisfaction with facial appear-ance was a significant predictor for all expectations oforthodontic treatment for subjects 17 years and older.Dental satisfaction was a significant predictor only forexpectations about self-image. Dental and facial satis-faction explained 16% of the variance on subjects'expectations about self-image.

In Table IV, the mean scores and standard deviationson all subscales of both questionnaires are presented forboth groups in 2002 and 2012. The mean scores fromthe present study were compared with the mean scoresfrom the study of Bos et al.2 Significant differencesbetween the subjects in this study and those from theearlier study were found for dental satisfaction and ex-pectations about general well-being. The subjects in2012 were significantly more satisfied with their teeththan were those in 2002 and had higher expectationsof orthodontic treatment for their general well-being.

The mean scores for the different age groups fromthe present study were compared with the mean scoresfor the same age groups from the study in 2002 using1-sample t tests. For subjects younger than 17 years,only 1 significant difference was found for facial satis-faction in both boys (2002, 55.75 [n 5 36]; 2012,60.79 [n 5 35]; t 5 3.00; P \0.01) and girls (2002,60.56 [n 5 36]; 2012, 57.32 [n 5 49]; t 5 �2.19;P \0.05). In 2012, boys younger than 17 years weresignificantly more satisfied with their facial appearancethan were the boys 10 years ago. Girls younger than17 years in 2012 were significantly less satisfied withtheir facial appearance than were the girls 10 years ago.

In Tables V and VI, the mean scores and standarddeviations on all subscales of both questionnairesare presented for the age groups 17 years and olderin 2002 and 2012. As illustrated in Tables V and VI,both sexes 17 years and older were significantlymore satisfied with their teeth in 2012 comparedwith 2002. Women 17 years and older, however,were significantly more satisfied with their facialappearance as well and had significantly higher expec-tations about general well-being and self-image thandid the women 10 years ago.

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Table II. Multiple regression for subjects #16 years of age

Expectation

General well-being Self-image/appearance Future dental health Oral function

b P b P b P b PSatisfaction with facial appearance 0.176 0.260 0.121 0.435 0.436 0.005y 0.251 0.194Satisfaction with dental appearance �0.177 0.258 �0.246 0.114 �0.458 0.003y �0.323 0.036*R 0.146 0.189 0.351 0.245Adjusted R2 �0.006 0.009 0.123 0.034

*P\0.05; yP\0.01.

Table III. Multiple regression for subjects $17 years of age

Expectation

General well-being Self-image/appearance Future dental health Oral function

ß P ß P ß P ß PSatisfaction with facial appearance 0.441 0.004y 0.372 0.011* 0.345 0.025* 0.343 0.028*Satisfaction with dental appearance �0.149 0.314 �0.385 0.009y �0.203 0.180 �0.098 0.523R 0.413 0.437 0.331 0.324Adjusted R2 0.133 0.156 0.071 0.064

*P\0.05; yP\0.01.

Table IV. Means and standard deviations of all subscales for the total groups in 2002 and 2012

Subscale

Total groups

t P

20022 (n 5 100) 2012 (n 5 134)

Mean SD Mean SDSatisfaction questionnaireGeneral facial satisfaction 56.04 10.59 56.76 10.24 0.804 0.420Dental satisfaction 5.99 1.86 6.49 1.87 3.116 0.002y

Expectation questionnaireGeneral well-being 26.54 10.93 28.90 13.21 1.986 0.049*Self-image/appearance 18.00 7.53 18.73 7.88 1.055 0.294Future dental health 19.70 5.97 19.35 5.93 �0.680 0.497Oral function 9.56 4.30 9.92 4.77 0.849 0.397

*P\0.05; yP\0.01.

van Wezel, Bos, and Prahl 701

DISCUSSION

In this study, decreased dentofacial satisfaction withincreasing age was found, as expected. This findingwas consistent with previous studies.2,31 Because theolder subjects were less satisfied with their dental andfacial appearance than the younger subjects, it is notsurprising that the older subjects expected moreimprovement in their self-image. Dental and facial sat-isfactions were significant predictors for all expecta-tions of orthodontic treatment in the older agegroup. For the younger subjects, facial satisfactionwas found to be a significant predictor only for expec-tations of orthodontic treatment about future dentalhealth. This was in contrast to previous studies. Philips

American Journal of Orthodontics and Dentofacial Orthoped

et al17 found that older patients showed more concernabout functional problems and future dental healththan did younger subjects, and Bos et al2 found thatdental and facial satisfactions were predictors for ex-pectations about general well-being in the youngerage group. Although female subjects were expectedto be less satisfied with their dentofacial appearance,no significant correlations were found between sex,satisfaction with dental and facial appearances, and ex-pectations of orthodontic treatment. Also, there was noeffect of malocclusion on dentofacial satisfaction. Thisresult was also found by Taylor et al.21

In comparison with the subjects in 2002, the subjectsin the 2012 study had significantly higher expectations

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Table V. Means and standard deviations on all subscales for men $17 years in 2002 and 2012

Subscales

Men

t P

20022 (n 5 11) 2012 (n 5 15)

Mean SD Mean SDGeneral facial satisfaction 53.36 10.98 52.53 9.90 �0.323 0.751Dental satisfaction 5.00 1.73 6.13 1.25 3.523 0.003*General well-being 26.73 6.23 27.57 13.66 0.230 0.821Self-image/appearance 19.73 8.15 17.20 7.59 �1.291 0.218Future dental health 21.82 4.26 20.20 6.56 �0.956 0.355Oral function 10.64 3.96 11.29 5.12 0.472 0.645

*P\0.01.

Table VI. Means and standard deviations of all subscales for women $17 years in 2002 and 2012

Subscales

Women

t P

20022 (n 5 17) 2012 (n 5 35)

Mean SD Mean SDGeneral facial satisfaction 48.94 9.01 54.03 9.95 3.027 0.005y

Dental satisfaction 5.12 1.50 5.77 1.78 2.181 0.036*General well-being 27.00 8.31 32.36 13.76 2.239 0.032*Self-image/appearance 19.00 5.85 22.26 8.41 2.263 0.030*Future dental health 19.00 5.72 19.62 6.11 0.589 0.560Oral function 9.47 3.86 10.33 4.36 1.137 0.264

*P\0.05; yP\0.01.

702 van Wezel, Bos, and Prahl

about orthodontic treatment. This was especially true forwomen aged 17 years and older. A reason for the higherexpectations of orthodontic treatment might be that or-thodontic treatment has become more common in TheNetherlands during the last decade.19 It can be assumedthat patients see friends and acquaintances who havebeen treated successfully and therefore have high expec-tations for their own orthodontic treatment.

Unexpectedly, the subjects in this study were moresatisfied with their dental and facial appearances thanwere those studied 10 years earlier. A possible explana-tion for the increased satisfaction over time may bethat decreased anterior crowding in the Dutch popula-tion was found between 1999 and 2005.19 Severalstudies have shown that anterior crowding is the mainreason for dissatisfaction with dental appearance.10-13

Some limitations of this study must be noted. First, itdescribes the responses of subjects applying to the Aca-demic Centre of Dentistry Amsterdam for orthodontictreatment. Therefore, our results cannot be used fororthodontic patients in general. Furthermore, the groupin 2002 might not be comparable with the group in2012. Both groups included different people whomight not be similar for socioeconomic status and

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malocclusion. However, because both groups were largesamples of subjects applying for orthodontic treatmentat the Academic Centre of Dentistry in Amsterdam, acomparison between them seemed acceptable. Addi-tionally, if the sample of subjects 17 years and olderhad been larger and the distribution of the sexes hadbeen more equal, it is possible that significant correla-tions between sex and satisfaction with dental and facialappearances would have been found. Finally, althoughthe reliability of the questionnaire on satisfaction withfacial appearance was high, that of the questionnaireon dental satisfaction was only moderate. To comparethe results of the 2012 study with the results from2002, the same items were used. To increase the reli-ability, more items could be added to the subscale ofdental satisfaction in a future study.

In our study, changes in dental and facial satisfactionand expectations of orthodontic treatment over timewere found. In the future, this study can be replicatedto examine whether there are tendencies towardincreasing dental and facial satisfactions and expecta-tions of orthodontic treatment over time. Additionally,to analyze the correlations between objective orthodon-tic treatment need and dental and facial satisfactions

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van Wezel, Bos, and Prahl 703

and treatment expectations, the index of orthodontictreatment need could be used.

CONCLUSIONS

1. The subjects in 2012 had higher expectations oforthodontic treatment about general well-beingthan did those studied in 2002, especially thewomen 17 years and older.

2. The subjects in this study were more satisfied withtheir dental and facial appearances than were thosestudied 10 years earlier.

3. No significant correlations were found between sex,satisfaction with dental and facial appearances, andexpectations of orthodontic treatment.

4. Facial satisfaction was a significant predictor for allexpectations of orthodontic treatment in subjects17 years and older. For the younger subjects, facialsatisfaction was found to be a significant predictoronly for expectations about future dental health.

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