Aesthetic perceptions and psychosocial impact of malocclusion: comparison between cleft and non-cleft patients and their parents

Aesthetic perceptions and psychosocial impact of malocclusion: comparison between cleft and... Summary Objective To evaluate the influence of dentofacial attractiveness using the ‘Psychosocial Impact of Dental Aesthetics Questionnaire’ (PIDAQ), Satisfaction with Life Scale (SWLS) and Aesthetic Component (AC) of the Index of Orthodontic Treatment Need (IOTN) in patients with cleft lip/palate (CLP), and non-cleft orthodontic patients (Non-CLP) and their parents. Materials and methods Eighty patients (aged 11–19 years) comprising 40 CLP and 40 non-CLP were administered the PIDAQ and SWLS questionnaires to be rated individually by the patients, along with IOTN-AC rated by the patients and their parents, respectively. The subjects were also sub-divided according to their age, i.e. pre-adolescent and adolescent. Results The PIDAQ subpart scores for aesthetic concern differed between the two groups, with a significantly (P < 0.02) lower scoring for the CLP group. The adolescent CLP group scored more negatively than the pre-adolescent group in the dental self-confidence and social impact sub-parts of PIDAQ. No significant differences were observed for satisfaction with life. The parents’ IOTN-AC score for both groups was significant (P < 0.05) greater than the patient’s score, especially for adolescent subjects. Limitations Non-condition specific questionnaires with restrictive sampling sizing and non-inclusion of parameters like stress coping mechanism etc. Conclusion The parents rated the malocclusion of their child more critically than the child itself. A majority of the CLP group had a problem in identifying themselves using the IOTN-AC as no photo existed depicting a Class III or edge-to-edge malocclusion. Attitudes, especially perceptions of the aesthetics of front teeth, are crucial factors influencing patient’s psychological self-concept, social confidence, and treatment need in CLP patients and non-CLP patients, having more relevance as the patient matures towards adolescence and adulthood. Introduction The prevalence of children born with a cleft lip/palate deformity in India is 27 000–33 000 clefts per year (1). An important aspect of investigation is whether and how much a patient’s psychosocial adjustment profile (e.g. self-esteem, social skills, and achievement) is affected by the ailment and treatment, considering the varied complexities in the presentation of cleft lip and palate (CLP) (2). Insights into their own attractiveness, especially with regard to the dentofacial area, in conjunction with the concomitant psychosocial impact play a role of significant consequence in orthodontic patients. Improved interpersonal relationships and thereby increased self-confidence are a direct result of positive social interactions (3, 4). It is not just the appearance and function of the dentofacial complex that is affected; malocclusion, in general, has repercussions on the psychosocial and economic aspects of patients’ lives (5). Individual apprehensions regarding aesthetics together with their supposed psychosocial impacts, are usually the main motivating factors for consulting an orthodontist for treatment (6, 7). Conventional methods of appraising treatment needs or outcomes mostly involve evaluating ‘norms’ derived from indices or measurements (either occlusal or from a cephalogram), which are then used to define the same parameters, i.e. need/outcome (8, 9). However, these approaches only reproduce the opinion of professionals. Therefore, they have a major shortcoming, as the literature demonstrates that stark inconsistencies exist between practitioner and layman perceptions of dentofacial aesthetics and subsequent orthodontic treatment need (10, 11). Patient perceptions can act as relevant indicators of treatment need and thus may complement conventional clinical measurements (12, 13). Treatment assessment should allow for the incorporation of diverse psychosocial aspects and their impact, such as enhancement of the quality of life (QoL), and patients’ own views related to body and life satisfaction (14, 15). Ranganathan et al. (16) reported that although studies comparing patient-reported outcomes are sporadic, many instruments exist for measuring these outcomes in different populations; however, no specific standard has been established. Eichenberger et al. (17) reported that perceived aesthetics differed between cleft and control subjects especially for the layman, and while the clinicians involved were not as critical as the general public, nonetheless the cleft group was scored lower than the control group. A study comparing viewpoints and professionals by Gkantidis et al. (18) highlighted similar results that the aesthetic perception of cleft patients was deemed lower for the layman than for the clinicians and patients’ parents. Another study by Gkantidis highlighted that CLP patients and their parents with quite satisfied with regard to aesthetics and oro-facial function. Their level of satisfaction increased with decreasing influence of the cleft on everyday life. The parents had reported a significant influence of the same on family life, while the patients however did not feel the same way (19). Delcides et al. (5) concluded that the perceived impact of dental aesthetics in most emotionally and socially normal adolescents is affected by the grade of malocclusion, oral health-related QoL and body satisfaction. Although both Broder et al and Turner et al have mentioned the lack of conclusive data supporting the influence of gender on life satisfaction in CLP care, two other studies have reported a trend that female cleft patients are less content and satisfied with their appearance than their male counterparts (20–23). Berk et al. (24) evaluated Chinese CLP patients and their psychological constructs, and their findings suggest that CLP patients are usually disadvantaged compared with non-cleft ones in terms of social contentment and adaptation. Another Chinese study assessed the emotional and mental wellness of CLP patients using the Social Avoidance and Distress Scale, Satisfaction with Life Scale (SWLS), Culture-Free Self-Esteem Inventory, and Chinese Miller Behavioural Style Scale. The authors concluded that the CLP group was equally content with life and exhibited almost the same anxiety (socially) as the non-CLP group. They also reported that among the parents of the CLP patients, the results were influenced by either gender or educational level (2). In CLP and non-CLP patients and their parents, our study aimed to evaluate the influence of dentofacial attractiveness through the Psychosocial Impact of Dental Aesthetics Questionnaire (PIDAQ) and SWLS, after both were translated and adapted cross-culturally for the regional language, i.e. Malayalam using the schematic given by Sardenberg et al. (25), and the self-rated Aesthetic Component (AC) of the Index of Orthodontic Treatment Need (IOTN-AC). We also sought to ascertain and verify if any relationship existed between the self-rated IOTN-AC scores and the PIDAQ and SWLS scores. Materials and methods This study was conducted over 3 months from October to December 2014 at the Government Dental College, Kottayam, after obtaining prior sanction from the scientific and ethical committee of the institution (M/07/2014/DCK). In this cross-sectional study, a power analysis was performed using a convenience sample of 80 [40 CLP and 40 orthodontic (non-CLP)] patients with an age range of 11–19 years. The sample size was calculated by considering 80 per cent as the power of the study (26). A further sub-division was also done to separate pre-adolescents (age less than 13 years) and adolescents based on the Classification given by Broadribb (27) n=f(α,β)×sd2(μ1−μ2)2. The inclusion criterion for the CLP group was a diagnosis of non-syndromic CLP. Patients in both the CLP and non-CLP groups had no prior orthodontic treatment history and had to be of Kerala origin. The patients were only included after proper informed consent was provided as and when they reported to the outpatient desk at the Department of Orthodontics, Government Dental College, Kottayam, Kerala, India. The CLP patients were usually referred from the Department of Plastic Surgery, Government Medical College, Kottayam and Alappuzha, Kerala, and the Department of Oral and Maxillofacial Surgery, Government Dental College, Kottayam whereas the non-CLP group consisted of regular patients who had consulted for routine orthodontic interventions for various malocclusions. Once informed consent was obtained, all patients were provided with the PIDAQ and SWLS questionnaires, along with a basic data sheet to record their age, sex, socioeconomic status, and other demographic data. They filled in the questionnaires in the waiting room of the post-graduate clinic of the Department of Orthodontics. In both groups, the patients and their parents individually graded their malocclusion by using the IOTN-AC grading chart. Psychosocial impact of dental aesthetics questionnaire (PIDAQ) A psychometric instrument comprising 23 items was used for assessing the orthodontic-oriented traits of QoL, which mainly consisted of four domains: dental self-confidence (DSC; six items), social impact (SI; eight items), psychological impact (PI; six items), and aesthetic concern (ASC; three items). The validity and reliability of PIDAQ have been previously tested (28). The subjects rated the positive or negative impact of dental aesthetics on a Likert scale ranging from 0 to 4 (0 indicated not at all; 1, a little; 2, somewhat; 3, strongly; and 4, very strongly). To ensure that the scoring pattern was in the same direction for all domains, for the DSC items, which scored a positive impact response, the scores were inverted to create a constant and reliable degree of impacts, without hampering the validity of the questionnaire. For adequate measurement of the psychosocial impact, the PIDAQ was translated and cross-culturally adapted into the regional language (Malayalam) according to the schematic followed by Sardenberg et al. (25) in their paper where they translated and validated the Brazilian version of PIDAQ. The process involved two translations from separate blinded translators and back-translations of the original questionnaire in English to Malayalam, finally culminating in a version that comprised the segments that best reflected the original questionnaire after semantic and linguistic appraisal. Testing the reliability of this questionnaire revealed Cronbach’s α values of 0.85–0.91, according to an unpublished initial pilot study of 50 patients and later of 379 subjects, which was conducted by the authors to test the reliability and validity (construct and criterion) of the translated questionnaire. This was consistent with the scales provided by Klages et al. (28) and Shek et al. (29). An overall total PIDAQ score was obtained by summation of the scores of all the items, and the domain scores were obtained by summing the item scores in each domain. Satisfaction with Life Scale (SWLS) As shown by Cochrane and Slade (30), SWLS evaluates subjective wellness in CLP patients. They demonstrated that SWLS has a decent 2-month test–retest internal consistency and reliability (Cronbach’s α =0.87). Biswas-Diener and Diener (31) tested this questionnaire in Calcutta slums. Furthermore, since the responses of pre-adolescents and adolescents may vary, a previously validated questionnaire which was modified for children was also used (32). Because the native language spoken in these two areas differs, this questionnaire was also cross-culturally adapted and pilot-tested in the local language, following which it was then applied to the study subjects. The patients in both groups answered to a seven-point Likert-type scale (ranging from ‘strongly disagree’ to ‘strongly agree’), and the following algorithm was employed to categorize the patients into different grades. A high degree of life satisfaction was indicated when the total score was 30–35, moderate life satisfaction when the score was 18–29, and low life satisfaction when the score was 5–17. Index of orthodontic treatment-aesthetic component (IOTN-AC) (33) The patients and their parents were individually presented with 10 coloured, anterior teeth photos showing varying grades of malocclusion and separately were asked to point out the grade (1–10) of the photograph that most resembled their own or their child’s dentition. No time limit was set for the self-rating of IOTN-AC. The IOTN-AC (33) grades were then used for subject grouping as follows: IOTN-AC score of 1 = first group IOTN-AC score of 2 = second group IOTN-AC score of 3 = third group IOTN-AC scores of 4–10 = fourth group (4+) The rationale for this grouping was that any grading beyond 4 would fall under the moderate-to-severe treatment need category which was the prime focus group of the study; hence this grouping was performed, to simplify the statistics and calculations. Statistical analysis All data were analysed using SPSS version 20.0 for Windows (SPSS Inc., Chicago, Illinois, USA). Descriptive statistics of the PIDAQ, SWLS, and IOTN-AC scores were obtained. Kruskal–Wallis ANOVA and Spearman correlation coefficient (two-tailed) were used to test for the presence of any differences in the mean/median of the responses between the two groups (CLP and Non-CLP; pre-adolescents and adolescents) and for any correlation among the scales, respectively; independent t-test was used to check for any gender differences. Values were considered statistically significant if P < 0.05. Results General descriptive data Age and gender distribution The age of the CLP patients ranged from 11 to 19 years, with the greatest number of respondents aged 13 years (20%), followed by those aged 11 years (15%), 12 years (15%), 15 years (15%); 10 years (10%), and 19 years (10%); the remaining 15 per cent were equally represented by the 14-, 17-, and 18-year age groups. The mean age for the CLP group was 14.2 ± 3.6 years, and the CLP group had equal gender distribution, i.e. 20 males and 20 females. The age of the non-CLP patients ranged from 12 to 19 years, with the greatest number of respondents aged 13 years (30%), followed by those aged 14 years (25%), 12 years (10%), 15 years (10%), and 16 years (10%); the remaining 15 per cent were equally represented by the 17-, 18-, and 19-year age groups. The mean age for the non-CLP group was 14.40 ± 1.90 years, and the non-CLP group also had equal gender distribution, i.e. 20 males and 20 females. Both groups had an equal number of pre-adolescents and adolescents as well i.e. 20 in each group. All subjects were either in high school or had received an education at the high school level, and the subjects in the 18- and 19-year age groups were college-going students. Socioeconomic status The modified Kuppuswamy scale (which periodically changes to adjust for inflation) was used to assess the socioeconomic status (34). Kruskal–Wallis ANOVA showed no significant differences in the responses between the two groups based on socio-economic status. Psychosocial impact of dental aesthetics questionnaire The descriptive distribution of PIDAQ scores for the CLP and non-CLP groups is listed in Table 1. In the CLP group, the DSC scores were highest and lowest for patients Classifying themselves as IOTN-AC grade 4 and above (mean score 16.0) and grade 1 (mean score of 8.0 because of the scoring reversal described in the methodology), respectively. In the non-CLP group, peak DSC scores were observed for those Classifying themselves as IOTN-AC grade 4 and above (mean score 22.0) and vice-versa for those Classifying themselves as grade 1 (mean score 6.50). Table 1. Descriptive distribution of PIDAQ, SWLS scores based on IOTN-AC scoring Group 1 Group 2 Psychological trait CLP group patients (N = 40) Non-CLP group patients (N = 40) Psychological trait CLP group patients (N = 40) Non-CLP group patients (N = 40) Mean ± SD Mean ± SD Mean ± SD Mean ± SD Dental self-confidence 8.00 ± 0.0 6.50 ± 0.0 Dental self-confidence 12.33 ± 8.31 12.00 ± 3.109 Social impact 12.00 ± 0.0 11.00 ± 0.0 Social impact 13.73 ± 12.423 10.71 ± 4.992 Psychosocial impact 13.00 ± 0.0 5.00 ± 0.0 Psychosocial impact 13.00 ± 9.165 14.00 ± 7.165 Aesthetic concern* 7.00 ± 0.0 3.00 ± 0.0 Aesthetic concern* 7.18 ± 5.686 6.50 ± 1.00 PIDAQ total 40.00 ± 0.0 21.00 ± 0.0 PIDAQ Total 48.33 ± 31.44 47.71 ± 9.77 Life satisfaction Total (category) 26.00 ± 0.0 (2) 27.00 ± 0.0 (2) Life satisfaction total (category) 26.33 ± 3.724 (2) 25.00 ± 3.11 (2) Group 3 Group 4+ Psychological trait CLP group patients (N = 40) Non-CLP group patients (N = 40) Psychological trait CLP group patients (N = 40) Non-CLP group patients (N = 40) Mean ± SD Mean ± SD Mean ± SD Mean ± SD Dental self-confidence 15.90 ± 6.92 13.14 ± 8.69 Dental self-confidence 16.00 ± 7.25 22.00 ± 1.71 Social impact 14.00 ± 6.595 11.75 ± 5.936 Social impact 15.67 ± 9.067 14.63 ± 6.989 Psychosocial impact 14.40 ± 4.393 14.50 ± 7.141 Psychosocial impact 15.45 ± 5.027 15.00 ± 6.568 Aesthetic concern* 7.33 ± 4.561 9.25 ± 2.116 Aesthetic concern* 7.40 ± 4.600 9.86 ± 2.915 PIDAQ total 49.8 ± 18.01 50.75 ± 14.48 PIDAQ Total 52.87 ± 17.58 60.37 ± 12.16 Life satisfaction total (category) 28.20 ± 2.44 (2) 25.71 ± 3.583 (2) Life satisfaction total (category) 26.18 ± 4.316 (2) 22.25 ± 4.37 (2) Group 1 Group 2 Psychological trait CLP group patients (N = 40) Non-CLP group patients (N = 40) Psychological trait CLP group patients (N = 40) Non-CLP group patients (N = 40) Mean ± SD Mean ± SD Mean ± SD Mean ± SD Dental self-confidence 8.00 ± 0.0 6.50 ± 0.0 Dental self-confidence 12.33 ± 8.31 12.00 ± 3.109 Social impact 12.00 ± 0.0 11.00 ± 0.0 Social impact 13.73 ± 12.423 10.71 ± 4.992 Psychosocial impact 13.00 ± 0.0 5.00 ± 0.0 Psychosocial impact 13.00 ± 9.165 14.00 ± 7.165 Aesthetic concern* 7.00 ± 0.0 3.00 ± 0.0 Aesthetic concern* 7.18 ± 5.686 6.50 ± 1.00 PIDAQ total 40.00 ± 0.0 21.00 ± 0.0 PIDAQ Total 48.33 ± 31.44 47.71 ± 9.77 Life satisfaction Total (category) 26.00 ± 0.0 (2) 27.00 ± 0.0 (2) Life satisfaction total (category) 26.33 ± 3.724 (2) 25.00 ± 3.11 (2) Group 3 Group 4+ Psychological trait CLP group patients (N = 40) Non-CLP group patients (N = 40) Psychological trait CLP group patients (N = 40) Non-CLP group patients (N = 40) Mean ± SD Mean ± SD Mean ± SD Mean ± SD Dental self-confidence 15.90 ± 6.92 13.14 ± 8.69 Dental self-confidence 16.00 ± 7.25 22.00 ± 1.71 Social impact 14.00 ± 6.595 11.75 ± 5.936 Social impact 15.67 ± 9.067 14.63 ± 6.989 Psychosocial impact 14.40 ± 4.393 14.50 ± 7.141 Psychosocial impact 15.45 ± 5.027 15.00 ± 6.568 Aesthetic concern* 7.33 ± 4.561 9.25 ± 2.116 Aesthetic concern* 7.40 ± 4.600 9.86 ± 2.915 PIDAQ total 49.8 ± 18.01 50.75 ± 14.48 PIDAQ Total 52.87 ± 17.58 60.37 ± 12.16 Life satisfaction total (category) 28.20 ± 2.44 (2) 25.71 ± 3.583 (2) Life satisfaction total (category) 26.18 ± 4.316 (2) 22.25 ± 4.37 (2) *Statistically significant difference (P < 0.05). View Large Table 1. Descriptive distribution of PIDAQ, SWLS scores based on IOTN-AC scoring Group 1 Group 2 Psychological trait CLP group patients (N = 40) Non-CLP group patients (N = 40) Psychological trait CLP group patients (N = 40) Non-CLP group patients (N = 40) Mean ± SD Mean ± SD Mean ± SD Mean ± SD Dental self-confidence 8.00 ± 0.0 6.50 ± 0.0 Dental self-confidence 12.33 ± 8.31 12.00 ± 3.109 Social impact 12.00 ± 0.0 11.00 ± 0.0 Social impact 13.73 ± 12.423 10.71 ± 4.992 Psychosocial impact 13.00 ± 0.0 5.00 ± 0.0 Psychosocial impact 13.00 ± 9.165 14.00 ± 7.165 Aesthetic concern* 7.00 ± 0.0 3.00 ± 0.0 Aesthetic concern* 7.18 ± 5.686 6.50 ± 1.00 PIDAQ total 40.00 ± 0.0 21.00 ± 0.0 PIDAQ Total 48.33 ± 31.44 47.71 ± 9.77 Life satisfaction Total (category) 26.00 ± 0.0 (2) 27.00 ± 0.0 (2) Life satisfaction total (category) 26.33 ± 3.724 (2) 25.00 ± 3.11 (2) Group 3 Group 4+ Psychological trait CLP group patients (N = 40) Non-CLP group patients (N = 40) Psychological trait CLP group patients (N = 40) Non-CLP group patients (N = 40) Mean ± SD Mean ± SD Mean ± SD Mean ± SD Dental self-confidence 15.90 ± 6.92 13.14 ± 8.69 Dental self-confidence 16.00 ± 7.25 22.00 ± 1.71 Social impact 14.00 ± 6.595 11.75 ± 5.936 Social impact 15.67 ± 9.067 14.63 ± 6.989 Psychosocial impact 14.40 ± 4.393 14.50 ± 7.141 Psychosocial impact 15.45 ± 5.027 15.00 ± 6.568 Aesthetic concern* 7.33 ± 4.561 9.25 ± 2.116 Aesthetic concern* 7.40 ± 4.600 9.86 ± 2.915 PIDAQ total 49.8 ± 18.01 50.75 ± 14.48 PIDAQ Total 52.87 ± 17.58 60.37 ± 12.16 Life satisfaction total (category) 28.20 ± 2.44 (2) 25.71 ± 3.583 (2) Life satisfaction total (category) 26.18 ± 4.316 (2) 22.25 ± 4.37 (2) Group 1 Group 2 Psychological trait CLP group patients (N = 40) Non-CLP group patients (N = 40) Psychological trait CLP group patients (N = 40) Non-CLP group patients (N = 40) Mean ± SD Mean ± SD Mean ± SD Mean ± SD Dental self-confidence 8.00 ± 0.0 6.50 ± 0.0 Dental self-confidence 12.33 ± 8.31 12.00 ± 3.109 Social impact 12.00 ± 0.0 11.00 ± 0.0 Social impact 13.73 ± 12.423 10.71 ± 4.992 Psychosocial impact 13.00 ± 0.0 5.00 ± 0.0 Psychosocial impact 13.00 ± 9.165 14.00 ± 7.165 Aesthetic concern* 7.00 ± 0.0 3.00 ± 0.0 Aesthetic concern* 7.18 ± 5.686 6.50 ± 1.00 PIDAQ total 40.00 ± 0.0 21.00 ± 0.0 PIDAQ Total 48.33 ± 31.44 47.71 ± 9.77 Life satisfaction Total (category) 26.00 ± 0.0 (2) 27.00 ± 0.0 (2) Life satisfaction total (category) 26.33 ± 3.724 (2) 25.00 ± 3.11 (2) Group 3 Group 4+ Psychological trait CLP group patients (N = 40) Non-CLP group patients (N = 40) Psychological trait CLP group patients (N = 40) Non-CLP group patients (N = 40) Mean ± SD Mean ± SD Mean ± SD Mean ± SD Dental self-confidence 15.90 ± 6.92 13.14 ± 8.69 Dental self-confidence 16.00 ± 7.25 22.00 ± 1.71 Social impact 14.00 ± 6.595 11.75 ± 5.936 Social impact 15.67 ± 9.067 14.63 ± 6.989 Psychosocial impact 14.40 ± 4.393 14.50 ± 7.141 Psychosocial impact 15.45 ± 5.027 15.00 ± 6.568 Aesthetic concern* 7.33 ± 4.561 9.25 ± 2.116 Aesthetic concern* 7.40 ± 4.600 9.86 ± 2.915 PIDAQ total 49.8 ± 18.01 50.75 ± 14.48 PIDAQ Total 52.87 ± 17.58 60.37 ± 12.16 Life satisfaction total (category) 28.20 ± 2.44 (2) 25.71 ± 3.583 (2) Life satisfaction total (category) 26.18 ± 4.316 (2) 22.25 ± 4.37 (2) *Statistically significant difference (P < 0.05). View Large Similarly, in the CLP group, the SI (mean score 15.67), PI (mean score, 15.45) and ASC (mean score 7.4) scores were highest and lowest in patients categorizing themselves as IOTN-AC grade 4+ and grade 1 (SI: mean score 12.0; PI: mean score 13.0; ASC: mean score 7.0), respectively. In the non-CLP group, a similar pattern was noted for the SI (mean score 14.63), PI (mean score 15.00), and ASC (mean score 9.86) scores, with the maximum values observed for IOTN-AC 4+ patients and the minimum for grade 1 patients (SI: mean score, 1.0; PI: mean score 5.0; ASC: mean score 3.0; Table 1). Regarding the patients’ PIDAQ scores, the CLP group had a mean score of 44.5 (SD 15.1), and the non-CLP group had a mean score of 56.7 (SD 13.4), the difference of which was not statistically significant. Statistically significant differences were observed in the parent AC scores between the two groups (P < 0.03) and in the ASC domain of the PIDAQ scores between the two groups (P < 0.02; Tables 1 and 2). No significant gender difference was observed in the scoring pattern of the PIDAQ. Adolescence status also showed no difference in the scoring pattern of PIDAQ in the non-CLP group, whereas the CLP group showed a lower scoring pattern in the DSC and SI sub-parts of PIDAQ with the adolescent group scoring lower in both sub-parts respectively (P < 0.05). Table 2. Kruskal–Wallis ANOVA comparing the responses in PIDAQ, SWLS, and IOTN-AC for both groups Parameter Test statistic Degree of freedom Significance Dental self-confidence 1.497 1 0.221 Social impact 0.388 1 0.533 Psychosocial impact 0.166 1 0.684 Aesthetic concern 29.911 1 0.02* PIDAQ total 0.477 1 0.490 Life satisfaction category 0.125 1 0.724 Patient’s AC category 0.666 1 0.414 Parent’s AC category 7.39 1 0.03* Parameter Test statistic Degree of freedom Significance Dental self-confidence 1.497 1 0.221 Social impact 0.388 1 0.533 Psychosocial impact 0.166 1 0.684 Aesthetic concern 29.911 1 0.02* PIDAQ total 0.477 1 0.490 Life satisfaction category 0.125 1 0.724 Patient’s AC category 0.666 1 0.414 Parent’s AC category 7.39 1 0.03* *P ≤ 0.05. View Large Table 2. Kruskal–Wallis ANOVA comparing the responses in PIDAQ, SWLS, and IOTN-AC for both groups Parameter Test statistic Degree of freedom Significance Dental self-confidence 1.497 1 0.221 Social impact 0.388 1 0.533 Psychosocial impact 0.166 1 0.684 Aesthetic concern 29.911 1 0.02* PIDAQ total 0.477 1 0.490 Life satisfaction category 0.125 1 0.724 Patient’s AC category 0.666 1 0.414 Parent’s AC category 7.39 1 0.03* Parameter Test statistic Degree of freedom Significance Dental self-confidence 1.497 1 0.221 Social impact 0.388 1 0.533 Psychosocial impact 0.166 1 0.684 Aesthetic concern 29.911 1 0.02* PIDAQ total 0.477 1 0.490 Life satisfaction category 0.125 1 0.724 Patient’s AC category 0.666 1 0.414 Parent’s AC category 7.39 1 0.03* *P ≤ 0.05. View Large Satisfaction with life scale Both groups had comparable life satisfaction scores, which are categorized as moderate in the CLP (mean 26.7; SD, 3.78) and non-CLP (mean 24.25; SD, 4.08) groups, with no significant gender differences between them (Table 1). Kruskal–Wallis ANOVA showed no significant distribution patterns for the scores of SWLS and PIDAQ. Adolescent status also showed no significant difference in scoring pattern. Index of orthodontic treatment-aesthetic component The descriptive distribution of the (patients’ and parents’) IOTN-AC scores of both groups have been summarized in Table 2. In the CLP and non-CLP groups, the mean IOTN-AC score of the patients was 4.90 (SD, 2.78) and 3.75 (SD, 1.94), respectively, and the mean parent score was 7.90 (SD, 2.29) and 5.80 (SD, 2.14), respectively. This difference in parental score was statistically significant. A statistically significant difference in the parental scores was also observed when the groups were assessed according to adolescent status, with the adolescent group’s parents being more critical of their ward’s malocclusion (P < 0.05). Correlations The IOTN-AC scores of the patients and parents in both groups were compared with their SWLS total score, using bivariate analysis (Spearman’s correlation coefficient; Table 3). The patient and parent AC scores showed a statistically significant (P < 0.05) correlation of 0.586 for the CLP group, and the PIDAQ total scores showed statistically significant (P < 0.05) correlations with the patients’ AC scores (0.504) and life satisfaction total score (−0.445) for the non-CLP group. Table 3. Correlation table between IOTN-AC, SWLS, and PIDAQ scores for both groups CLP group (N = 40) Non-CLP group (N = 40) Patients AC grade Life satisfaction total Parents AC PIDAQ total Patients AC grade Life satisfaction total Parents AC PIDAQ total Spearman’s rho Patients AC grade Correlation Coefficient 1 −0.048 0.586* 0.137 1 −0.346 0.205 0.504* Sig. (two-tailed) 0.768 0.000* 0.399 0.029 0.205 0.001* Life satisfaction total Correlation Coefficient −0.048 1 0.044 0.043 −0.346 1 0.202 −0.445* Sig. (two-tailed) 0.768 0.790 0.793 0.029 0.211 0.004* Parent’s AC Correlation Coefficient 0.586 −0.048 1 0.125 0.205 0.202 1 −0.298 Sig. (two-tailed) 0.000 0.768 0.442 0.205 0.211 0.071 PIDAQ total Correlation Coefficient 0.137 0.043 0.125 1 0.504* −0.445* −0.298 1 Sig. (two-tailed) 0.399 0.793 0.442 0.001* 0.004* 0.071 CLP group (N = 40) Non-CLP group (N = 40) Patients AC grade Life satisfaction total Parents AC PIDAQ total Patients AC grade Life satisfaction total Parents AC PIDAQ total Spearman’s rho Patients AC grade Correlation Coefficient 1 −0.048 0.586* 0.137 1 −0.346 0.205 0.504* Sig. (two-tailed) 0.768 0.000* 0.399 0.029 0.205 0.001* Life satisfaction total Correlation Coefficient −0.048 1 0.044 0.043 −0.346 1 0.202 −0.445* Sig. (two-tailed) 0.768 0.790 0.793 0.029 0.211 0.004* Parent’s AC Correlation Coefficient 0.586 −0.048 1 0.125 0.205 0.202 1 −0.298 Sig. (two-tailed) 0.000 0.768 0.442 0.205 0.211 0.071 PIDAQ total Correlation Coefficient 0.137 0.043 0.125 1 0.504* −0.445* −0.298 1 Sig. (two-tailed) 0.399 0.793 0.442 0.001* 0.004* 0.071 *Statistically significant (P < 0.05) (two-tailed). View Large Table 3. Correlation table between IOTN-AC, SWLS, and PIDAQ scores for both groups CLP group (N = 40) Non-CLP group (N = 40) Patients AC grade Life satisfaction total Parents AC PIDAQ total Patients AC grade Life satisfaction total Parents AC PIDAQ total Spearman’s rho Patients AC grade Correlation Coefficient 1 −0.048 0.586* 0.137 1 −0.346 0.205 0.504* Sig. (two-tailed) 0.768 0.000* 0.399 0.029 0.205 0.001* Life satisfaction total Correlation Coefficient −0.048 1 0.044 0.043 −0.346 1 0.202 −0.445* Sig. (two-tailed) 0.768 0.790 0.793 0.029 0.211 0.004* Parent’s AC Correlation Coefficient 0.586 −0.048 1 0.125 0.205 0.202 1 −0.298 Sig. (two-tailed) 0.000 0.768 0.442 0.205 0.211 0.071 PIDAQ total Correlation Coefficient 0.137 0.043 0.125 1 0.504* −0.445* −0.298 1 Sig. (two-tailed) 0.399 0.793 0.442 0.001* 0.004* 0.071 CLP group (N = 40) Non-CLP group (N = 40) Patients AC grade Life satisfaction total Parents AC PIDAQ total Patients AC grade Life satisfaction total Parents AC PIDAQ total Spearman’s rho Patients AC grade Correlation Coefficient 1 −0.048 0.586* 0.137 1 −0.346 0.205 0.504* Sig. (two-tailed) 0.768 0.000* 0.399 0.029 0.205 0.001* Life satisfaction total Correlation Coefficient −0.048 1 0.044 0.043 −0.346 1 0.202 −0.445* Sig. (two-tailed) 0.768 0.790 0.793 0.029 0.211 0.004* Parent’s AC Correlation Coefficient 0.586 −0.048 1 0.125 0.205 0.202 1 −0.298 Sig. (two-tailed) 0.000 0.768 0.442 0.205 0.211 0.071 PIDAQ total Correlation Coefficient 0.137 0.043 0.125 1 0.504* −0.445* −0.298 1 Sig. (two-tailed) 0.399 0.793 0.442 0.001* 0.004* 0.071 *Statistically significant (P < 0.05) (two-tailed). View Large Discussion A limited number of studies have attempted to identify a relationship between subjects categorized in the groups of ‘marginal-to-severe’ treatment need on the basis of their self-rated IOTN-AC scores (4). According to the literature, no studies so far evaluated this relation in the South Indian (Central Kerala) population nor have they attempted to study the difference between CLP and non-CLP patients with the inclusion of their parents’ perspectives. Although the ethical appropriateness of parents judging their children (who in this study were as old as 19 years) is debatable, during the history taking, we constantly observed that the parents were more anxious and concerned about the treatment plan than were their children. In addition, considering the major prevalence of arranged marriages in this region, the parents are often and usually more concerned about their child’s appearance because, in their opinion, this would affect the demand for suitors for their ward/child as even older literature has cited the importance of facial attractiveness in being selected and deemed as a ‘better mate’ (35–40). This scoring pattern difference was highlighted in the study by the parental score i.e. their perception worsened as their ward moved towards adolescence and adulthood in both groups. Therefore, it is pertinent that parents are counselled as well as the patient, especially if the patient is of adolescent age. Psychosocial impact of dental aesthetics questionnaire Comparison of the scores of the four PIDAQ domains, DSC, SI, PI, and ASC, with the IOTN-AC grade 1 to 4+ scores, which were given by the subjects and parents, highlights the clear psychosocial impact of sub-normal/altered dental aesthetics, and this was evident in both groups (Table 1). The DSC domain deals with the satisfaction/dissatisfaction with one’s own dentition appearance, and it indirectly assesses how an individual’s self-image is affected by their appearance, taking into consideration how this perceived notion of facial attractiveness contributes to one’s self-concept and self-esteem (2, 41, 42). The previous statement was highlighted by our results, which showed decreasing DSC scores when the study subjects’ perceived their dentofacial aesthetics as sub-normal/diminished, according to IOTN-AC. This was in concurrence with the findings of Klages et al. (28), who stated that well-aligned teeth (marked by low IOTN-AC scores) indicate more favourable oral-health attitudes and greater satisfaction with dentofacial attractiveness, culminating in better self-concept. Both groups had similar scoring patterns and trends, indicating that the DSC scores were equally affected in the two groups, without any remarkable difference. SI forecasts the difficulties faced in public situations because of a self-perceived unfavourable dental appearance. Individuals experience positive peer interactions and evaluations more often if they are socially considered to be more attractive (41, 42). Our study revealed the impact of this parameter and the negative influence of social assessment of attractiveness by peers, without any notable difference between the two groups. The phenomenon of ‘social-comparison’, where aesthetic-based self-concept is influenced to such a degree that it can end up as a social handicap of sorts, could explain the findings of this study (41). In addition, Onyeaso et al. (42) stated that approximately 40 per cent of their study subjects had low or restricted confidence during public interactions, such as laughing, because of their abnormal dental features. They also reported depression in 27 per cent of their subjects, which was attributed to poor dentofacial aesthetics. However, in the CLP group, the scoring pattern decreased as the subjects matured towards adolescence indicating the greater impact of dentofacial attractiveness in their self-confidence and the associated SI it had in peer-to-peer interaction. This may affect their chances in maintaining a normal social posture in various aspects like employment, dating etc. and hence this finding should be investigated further to yield some light on the same. Furthermore, the associated SI of their condition should be looked into especially during the treatment planning process. This may include the choice and type of mechanotherapy (metal versus ceramic brackets, lingual appliances, clear aligners etc) especially with respect to the appliance’s appearance and subsequent duration of wear. Self-comparison with others leading to one’s own dissatisfaction/lowliness is assessed through PI. To quote Tung and Kiyak (41), ‘Researchers have consistently found that self-concept is related more to the individual’s perceptions of others’ evaluations than to objective evaluations by others’. In this study, high and low AC scoring grades were associated with reduced wellness psychologically when the dental aesthetics gradually declined. Similar to the other domains, no significant differences were noted between the two groups, indicating similar psychological patterns. The fourth domain of PIDAQ (i.e. ASC) comprises statements towards one’s disapproval of one’s own dental aesthetics in mirror reflections and pictures (static or motion). This explains why aesthetic correction is commonly one of the main motivations for seeking orthodontic correction. Our results showed a statistically significant difference in responses between the two groups (Tables 1 and 2), indicating that this motivation is higher among CLP patients. Because a comparative study of CLP and non-CLP patients have not been performed using PIDAQ, these findings could shed some light on the psychological profile of both groups. A greater treatment need for malocclusion, which is self-perceived in ascending grades of malocclusion, was observed by Mandall et al. (43), who stated that those who are teased about their teeth actively seek orthodontic treatment. While it is deemed appropriate to use a questionnaire like COHIP, since the study sample has an age range which includes pre-adolescents as well as adolescents, a wider age ranged and validated questionnaire like PIDAQ could serve and measure the intended parameters better. Satisfaction with life scale Both groups had comparable life satisfaction scores, which were categorized as moderate; this finding is consistent with previous data on CLP and routine patients (2). No significant differences were observed between the two groups as independent t-tests showed very similar scores for both groups, with no differences for gender and socioeconomic status. Index of orthodontic treatment need-aesthetic component No relationship was observed between parents’ AC rating and PIDAQ scores; this coupled with the fact that parents rated the malocclusion more critically especially as patients progressed towards adolescence and adulthood, indicates that patients’ scores should serve as a better baseline to assess the psychosocial impact of their malocclusion. In addition, excessively anxious or critical parents must be carefully managed and counselled, if necessary, so that parental psychological support to the patients, especially CLP patients, can be adequately provided during treatment. Interestingly, the CLP patients expressed some difficulty in grading themselves according to the original IOTN AC grading chart. This difficulty arose from the fact that no pictures of an anterior crossbite or of a Class III dentition were provided. Given the fact that the IOTN has been tool most widely used in the literature to screen patients (which allows comparison with findings from other studies), this coincidental finding could be further investigated to modify the existing AC grading chart to make it more suitable for CLP patients. Correlations In the CLP group, a positive and significant correlation of 0.586 was observed between the AC scores of patients and parents (P < 0.05) i.e. approximately half the time, the perceptions of the parent and the patients differed. In the non-CLP group, statistically significant (P < 0.05) correlations were observed between the PIDAQ total scores and patients’ AC scores (0.504) and between the PIDAQ scores and life satisfaction total scores (−0.445). This indicates the potential impact that altered dentofacial aesthetics has on an individual’s social and mental well-being. Also as previously mentioned, the CLP group had some difficulty in relating to the IOTN-AC scoring chart; this could explain the significant correlation between the parental and patient scoring, as this was not observed in the non-CLP group. Moreover, the PIDAQ and patient AC scores showed significant correlation, which is in line with previous findings (5, 28). Regarding the non-CLP group, to the best of our knowledge, few studies have examined the correlation of SWLS and PIDAQ scores (2); however, the significant negative correlation between the two indicates the impact of sub-normal/poor dentofacial aesthetics and its potential impact on life satisfaction, even though no significant difference was found between the groups. A larger sample could be fruitful in assessing this unique psychosocial correlation between these two scales. Limitations and future scope The results show a decisive pattern indicating that the impact of malocclusion (psychosocial) has an inverse relationship with IOTN-AC grade and overall psychosocial wellness. Additional studies with a larger sample may be needed to corroborate our findings because, in the present study, a sample of 80 was assessed, which may not provide adequate representation. Future studies could evaluate additional parameters such as coping mechanisms for stress, the anxiety levels of patients and parents, and the influence of age and education on psychosocial development. The questionnaires used in this study, namely SWLS and PIDAQ, are both generic. A future study using a condition-specific questionnaire (specific to clefts) could detect minor but important psychosocial aspects with regard to the targeted group (i.e. CLP). Moreover, a study could also be attempted to distinguish the responses between unilateral and bilateral cleft patients as well. The psychological needs of the patients must be considered and catered to during treatment planning, thereby facilitating more thorough rehabilitation. Additional studies involving a larger sample and other instruments (subjective or objective), could be conducted to substantiate these results. Conclusion This study focused on evaluating the differences among the self- concept, life satisfaction, and psychosocial impact of malocclusion in CLP and non-CLP orthodontic patients and their parents. No difference was observed in life satisfaction between the two groups as estimated using the SWLS (normal and that adapted for pre-adolescents). The parents of both groups rated the malocclusion more critically than did the patients and sometimes may require counselling and appropriate management with a more critical scoring trend as the patient’s age moves towards adolescence and adulthood. Major differences were observed regarding psychosocial wellbeing, with the CLP group rating themselves with a lower score in relation to ASC. The CLP group adolescents also scored lower in the DSC and SI sub-parts compared to the pre-adolescent CLP group. This indicates that the self-assessment of one’s own attractiveness, especially for dentofacial irregularities can contribute significantly in ascertaining the need for treatment, its associated psychosocial impact and the severity of the afflicted condition. Funding The study received no external funding to conduct this research through any of the authors involved. Conflict of Interest None to declare. Acknowledgements This manuscript was presented at 4th Virtual World Dental Congress held online from May 14th to 16th 2014 and awarded the first place. This manuscript was awarded the 750$ Charles Schultz Research Scholar Award at the Annual Session of the American Association of Orthodontists (AAO) held at San Francisco from May 15th to 19th 2015. This manuscript has been selected and accepted for presentation in International Cleft Congress 2017 in the ORAL FREE PAPER CATEGORY. References 1. Mossey , P. and Little , J . ( 2009 ) Addressing the challenges of cleft lip and palate research in India . Indian Journal of Plastic Surgery , 42 ( Suppl ), S9 – S18 . Google Scholar CrossRef Search ADS 2. Cheung , L.K. , Loh , J.S. and Ho , S.M . ( 2007 ) Psychological profile of Chinese with cleft lip and palate deformities . The Cleft Palate Craniofacial Journal , 44 , 79 – 86 . Google Scholar CrossRef Search ADS 3. Allyn & Bacon . ( 1999 ) Social thought and social behaviour . In Baron , R.A . (ed.), Essentials of psychology . 2nd ed , Pearson Publishing, Massachusetts , pp. 535 – 66 . 4. Bos , A. , Hoogstraten , J. and Prahl-Andersen , B . ( 2003 ) Expectations of treatment and satisfaction with dentofacial appearance in orthodontic patients . American Journal of Orthodontics and Dentofacial Orthopedics , 123 , 127 – 132 . Google Scholar CrossRef Search ADS 5. Delcides , F. de Paula Jr , Nádia , C.M. , Santos , S.E.T. , Nunes , M.F. and Leles , C.R . ( 2009 ) Psychosocial impact of dental esthetics on quality of life in adolescents association with malocclusion, self-image, and oral health–related issues . The Angle Orthodontist , 79 , 1188 – 1193 . Google Scholar CrossRef Search ADS 6. Azuma , S. , Kohzuki , M. , Saeki , S. , Tajima , M. , Igarashi , K. and Sugawara , J . ( 2008 ) Beneficial effects of orthodontic treatment on quality of life in patients with malocclusion . The Tohoku Journal of Experimental Medicine , 214 , 39 – 50 . Google Scholar CrossRef Search ADS 7. Bernabé , E. , Tsakos , G. , Messias de Oliveira , C. and Sheiham , A . ( 2008 ) Impacts on daily performances attributed to malocclusions using the condition-specific feature of the Oral Impacts on Daily Performances Index . The Angle Orthodontist , 78 , 241 – 247 . Google Scholar CrossRef Search ADS 8. Bernabé , E. and Flores-Mir , C . ( 2006 ) Orthodontic treatment need in Peruvian young adults evaluated through dental aesthetic index . The Angle Orthodontist , 76 , 417 – 421 . 9. Hamdan , A.M. , Al-Omari , I.K. and Al-Bitar , Z.B . ( 2007 ) Ranking dental aesthetics and thresholds of treatment need: a comparison between patients, parents, and dentists . European Journal of Orthodontics , 29 , 366 – 371 . Google Scholar CrossRef Search ADS 10. Hamdam , A.M . ( 2004 ) The relationship between patient, parent and clinician perceived need and normative orthodontic treatment need . European Journal of Orthodontics , 26 , 265 – 271 . Google Scholar CrossRef Search ADS 11. Gherunpong , S. , Tsakos , G. and Sheiham , A . ( 2006 ) A socio-dental approach to assessing children’s orthodontic needs . European Journal of Orthodontics , 28 , 393 – 399 . Google Scholar CrossRef Search ADS 12. de Oliveira , C.M. and Sheiham , A . ( 2003 ) The relationship between normative orthodontic treatment need and oral health-related quality of life . Community Dentistry and Oral Epidemiology , 31 , 426 – 436 . Google Scholar CrossRef Search ADS 13. Klages , U. , Bruckner , A. and Zentner , A . ( 2004 ) Dental aesthetics, self-awareness, and oral health-related quality of life in young adults . European Journal of Orthodontics , 26 , 507 – 514 . Google Scholar CrossRef Search ADS 14. Tajima , M. , Kohzuki , M. , Azuma , S. , Saeki , S. , Meguro , M. and Sugawara , J . ( 2007 ) Difference in quality of life according to the severity of malocclusion in Japanese orthodontic patients . The Tohoku Journal of Experimental Medicine , 212 , 71 – 80 . Google Scholar CrossRef Search ADS 15. Phillips , C. and Beal , K.N . ( 2009 ) Self-concept and the perception of facial appearance in children and adolescents seeking orthodontic treatment . The Angle Orthodontist , 79 , 12 – 16 . Google Scholar CrossRef Search ADS 16. Ranganathan , K. , Vercler , C.J. , Warschausky , S.A. , MacEachern , M.P. , Buchman , S.R. and Waljee , J.F . ( 2015 ) Comparative effectiveness studies examining patient-reported outcomes among children with cleft lip and/or palate: a systematic review . Plastic and Reconstructive Surgery , 135 , 198 – 211 . Google Scholar CrossRef Search ADS 17. Eichenberger , M. , Staudt , C.B. , Pandis , N. , Gnoinski , W. and Eliades , T . ( 2014 ) Facial attractiveness of patients with unilateral cleft lip and palate and of controls assessed by laypersons and professionals . European Journal of Orthodontics , 36 , 284 – 289 . Google Scholar CrossRef Search ADS 18. Gkantidis , N. , Papamanou , D.A. , Christou , P. and Topouzelis , N . ( 2013 ) Aesthetic outcome of cleft lip and palate treatment. Perceptions of patients, families, and health professionals compared to the general public . Journal of Cranio-Maxillo-Facial Surgery , 41 , e105 – e110 . Google Scholar CrossRef Search ADS 19. Gkantidis , N. , Papamanou , D.A. , Karamolegkou , M. and Dorotheou , D . ( 2015 ) Esthetic, functional, and everyday life assessment of individuals with cleft lip and/or palate . BioMed Research International , 2015 , 510395 . Google Scholar CrossRef Search ADS 20. Broder , H.L. , Smith , F.B. and Strauss , R.P . ( 1992 ) Habilitation of patients with clefts: parent and child ratings of satisfaction with speech . Cleft Palate Craniofac J , 29 , 262 – 267 . Google Scholar CrossRef Search ADS 21. Turner , S.R. , Rumsey , N. and Sandy , J.R . ( 1998 ) Psychological aspects of cleft lip and palate . European Journal of Orthodontics , 20 , 407 – 415 . Google Scholar CrossRef Search ADS 22. Berscheid , E. and Gangestad , S . ( 1982 ) The social psychological implications of facial physical attractiveness . Clinics in Plastic Surgery , 9 , 289 – 296 . 23. Broder , H.L. and Strauss , R.P . ( 1989 ) Self-concept of early primary school age children with visible or invisible defects . Cleft Palate J , 24 , 158 – 163 . 24. Berk , N.W. , Cooper , M.E. , Liu , Y.E. and Marazita , M.L . ( 2001 ) Social anxiety in Chinese adults with oral-facial clefts . The Cleft Palate-Craniofacial Journal , 38 , 126 – 133 . Google Scholar CrossRef Search ADS 25. Sardenberg , F. , Oliveira , A.C. , Paiva , S.M. , Auad , S.M. and Vale , M.P . ( 2011 ) Validity and reliability of the Brazilian version of the psychosocial impact of dental aesthetics questionnaire . European Journal of Orthodontics , 33 , 270 – 275 . Google Scholar CrossRef Search ADS 26. Pandis , N. , Polychronopoulou , A. and Eliades , T . ( 2011 ) Sample size estimation: an overview with applications to orthodontic clinical trial designs . American Journal of Orthodontics and Dentofacial Orthopedics , 140 , e141 – e146 . Google Scholar CrossRef Search ADS 27. Hartfield N . ( 2008 ) Broadribb’s Introductory Pediatric Nursing . Lippincott Williams & Wilkins , 7th edn , pp. 588 28. Klages , U. , Claus , N. , Wehrbein , H. and Zentner , A . ( 2006 ) Development of a questionnaire for assessment of the psychosocial impact of dental aesthetics in young adults . European Journal of Orthodontics , 28 , 103 – 111 . Google Scholar CrossRef Search ADS 29. Shek DT . ( 1998 ) Adolescent positive mental health and psychological symptoms: a longitudinal study in a Chinese context . Psychologia: Int J Psychol Orient , 41 , 217 – 225 . 30. Cochrane , V.M. and Slade , P . ( 1999 ) Appraisal and coping in adults with cleft lip: associations with well-being and social anxiety . British Journal of Medical Psychology , 72 ( Pt 4 ), 485 – 503 . Google Scholar CrossRef Search ADS 31. Biswas-Diener , D . ( 2001 ) Making the best of a bad situation: satisfaction in the slums of calcutta . Social Indicators Research , 55 , 29 – 352 . Google Scholar CrossRef Search ADS 32. Gadermann , A.M. , Schonert-Reichl , K.A. and Zumbo , B.D . ( 2010 ) Investigating validity evidence of the Satisfaction with Life Scale adapted for Children . Social Indicators Research , 96 , 229 – 247 . Google Scholar CrossRef Search ADS 33. Brook , P.H. and Shaw , W.C . ( 1989 ) The development of an index of orthodontic treatment priority . European Journal of Orthodontics , 11 , 309 – 320 . Google Scholar CrossRef Search ADS 34. Gururaj , M . ( 2014 ) Kuppuswamy’s Socio-Economic Status Scale – a revision of income parameter for 2014 . International Journal of Recent Trends in Science and Technology , 11 , 01 – 02 . Google Scholar CrossRef Search ADS 35. Møller , A.P. and Thornhill , R . ( 1998 ) Bilateral symmetry and sexual selection: a meta-analysis . The American Naturalist , 151 , 174 – 192 . Google Scholar CrossRef Search ADS 36. Elder , G.H. Jr . ( 1969 ) Appearance and education in marriage mobility . American Sociological Review , 34 , 519 – 533 . Google Scholar CrossRef Search ADS 37. Holmes , S.J. and Hatch , C.E . ( 1938 ) Personal appearance as related to scholastic records and marriage selection in college women . Human Biology , 10 , 65 – 76 38. Riggio , R. and Woll , S . ( 1984 ) The role of non-verbal and physical attractiveness in the selection of dating partners . Journal of Social and Personal Relationships , 1 , 347 – 357 . Google Scholar CrossRef Search ADS 39. Berscheid , E. , Dion , K. , Walster , E. and Walster , G.W . ( 1971 ) Physical attractiveness and dating choice: a test of the matching hypothesis . Journal of Experimental Social Psychology , 7 , 173 – 189 . Google Scholar CrossRef Search ADS 40. Little , A.C. , Jones , B.C. and DeBruine , L.M . ( 2011 ) Facial attractiveness: evolutionary based research . Philosophical Transactions of the Royal Society of London Series B: Biological Sciences , 366 , 1638 – 1659 . Google Scholar CrossRef Search ADS 41. Tung , A.W. and Kiyak , H.A . ( 1998 ) Psychological influences on the timing of orthodontic treatment . American Journal of Orthodontics and Dentofacial Orthopedics , 113 , 29 – 39 . Google Scholar CrossRef Search ADS 42. Onyeaso , C.O. , Utomi , I.L. and Ibekwe , T.S . ( 2005 ) Emotional effects of malocclusion in Nigerian orthodontic patients . The Journal of Contemporary Dental Practice , 6 , 64 – 73 . 43. Mandall , N.A. , Wright , J. , Conboy , F. , Kay , E. , Harvey , L. and O’Brien , K.D . ( 2005 ) Index of orthodontic treatment need as a predictor of orthodontic treatment uptake . American Journal of Orthodontics and Dentofacial Orthopedics , 128 , 703 – 707 . Google Scholar CrossRef Search ADS © The Author(s) 2018. Published by Oxford University Press on behalf of the European Orthodontic Society. All rights reserved. For permissions, please email: journals.permissions@oup.com This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/about_us/legal/notices) http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png The European Journal of Orthodontics Oxford University Press

Aesthetic perceptions and psychosocial impact of malocclusion: comparison between cleft and non-cleft patients and their parents

Loading next page...
 
/lp/ou_press/aesthetic-perceptions-and-psychosocial-impact-of-malocclusion-909Fcv9mKl
Publisher
Oxford University Press
Copyright
© The Author(s) 2018. Published by Oxford University Press on behalf of the European Orthodontic Society. All rights reserved. For permissions, please email: journals.permissions@oup.com
ISSN
0141-5387
eISSN
1460-2210
D.O.I.
10.1093/ejo/cjy022
Publisher site
See Article on Publisher Site

Abstract

Summary Objective To evaluate the influence of dentofacial attractiveness using the ‘Psychosocial Impact of Dental Aesthetics Questionnaire’ (PIDAQ), Satisfaction with Life Scale (SWLS) and Aesthetic Component (AC) of the Index of Orthodontic Treatment Need (IOTN) in patients with cleft lip/palate (CLP), and non-cleft orthodontic patients (Non-CLP) and their parents. Materials and methods Eighty patients (aged 11–19 years) comprising 40 CLP and 40 non-CLP were administered the PIDAQ and SWLS questionnaires to be rated individually by the patients, along with IOTN-AC rated by the patients and their parents, respectively. The subjects were also sub-divided according to their age, i.e. pre-adolescent and adolescent. Results The PIDAQ subpart scores for aesthetic concern differed between the two groups, with a significantly (P < 0.02) lower scoring for the CLP group. The adolescent CLP group scored more negatively than the pre-adolescent group in the dental self-confidence and social impact sub-parts of PIDAQ. No significant differences were observed for satisfaction with life. The parents’ IOTN-AC score for both groups was significant (P < 0.05) greater than the patient’s score, especially for adolescent subjects. Limitations Non-condition specific questionnaires with restrictive sampling sizing and non-inclusion of parameters like stress coping mechanism etc. Conclusion The parents rated the malocclusion of their child more critically than the child itself. A majority of the CLP group had a problem in identifying themselves using the IOTN-AC as no photo existed depicting a Class III or edge-to-edge malocclusion. Attitudes, especially perceptions of the aesthetics of front teeth, are crucial factors influencing patient’s psychological self-concept, social confidence, and treatment need in CLP patients and non-CLP patients, having more relevance as the patient matures towards adolescence and adulthood. Introduction The prevalence of children born with a cleft lip/palate deformity in India is 27 000–33 000 clefts per year (1). An important aspect of investigation is whether and how much a patient’s psychosocial adjustment profile (e.g. self-esteem, social skills, and achievement) is affected by the ailment and treatment, considering the varied complexities in the presentation of cleft lip and palate (CLP) (2). Insights into their own attractiveness, especially with regard to the dentofacial area, in conjunction with the concomitant psychosocial impact play a role of significant consequence in orthodontic patients. Improved interpersonal relationships and thereby increased self-confidence are a direct result of positive social interactions (3, 4). It is not just the appearance and function of the dentofacial complex that is affected; malocclusion, in general, has repercussions on the psychosocial and economic aspects of patients’ lives (5). Individual apprehensions regarding aesthetics together with their supposed psychosocial impacts, are usually the main motivating factors for consulting an orthodontist for treatment (6, 7). Conventional methods of appraising treatment needs or outcomes mostly involve evaluating ‘norms’ derived from indices or measurements (either occlusal or from a cephalogram), which are then used to define the same parameters, i.e. need/outcome (8, 9). However, these approaches only reproduce the opinion of professionals. Therefore, they have a major shortcoming, as the literature demonstrates that stark inconsistencies exist between practitioner and layman perceptions of dentofacial aesthetics and subsequent orthodontic treatment need (10, 11). Patient perceptions can act as relevant indicators of treatment need and thus may complement conventional clinical measurements (12, 13). Treatment assessment should allow for the incorporation of diverse psychosocial aspects and their impact, such as enhancement of the quality of life (QoL), and patients’ own views related to body and life satisfaction (14, 15). Ranganathan et al. (16) reported that although studies comparing patient-reported outcomes are sporadic, many instruments exist for measuring these outcomes in different populations; however, no specific standard has been established. Eichenberger et al. (17) reported that perceived aesthetics differed between cleft and control subjects especially for the layman, and while the clinicians involved were not as critical as the general public, nonetheless the cleft group was scored lower than the control group. A study comparing viewpoints and professionals by Gkantidis et al. (18) highlighted similar results that the aesthetic perception of cleft patients was deemed lower for the layman than for the clinicians and patients’ parents. Another study by Gkantidis highlighted that CLP patients and their parents with quite satisfied with regard to aesthetics and oro-facial function. Their level of satisfaction increased with decreasing influence of the cleft on everyday life. The parents had reported a significant influence of the same on family life, while the patients however did not feel the same way (19). Delcides et al. (5) concluded that the perceived impact of dental aesthetics in most emotionally and socially normal adolescents is affected by the grade of malocclusion, oral health-related QoL and body satisfaction. Although both Broder et al and Turner et al have mentioned the lack of conclusive data supporting the influence of gender on life satisfaction in CLP care, two other studies have reported a trend that female cleft patients are less content and satisfied with their appearance than their male counterparts (20–23). Berk et al. (24) evaluated Chinese CLP patients and their psychological constructs, and their findings suggest that CLP patients are usually disadvantaged compared with non-cleft ones in terms of social contentment and adaptation. Another Chinese study assessed the emotional and mental wellness of CLP patients using the Social Avoidance and Distress Scale, Satisfaction with Life Scale (SWLS), Culture-Free Self-Esteem Inventory, and Chinese Miller Behavioural Style Scale. The authors concluded that the CLP group was equally content with life and exhibited almost the same anxiety (socially) as the non-CLP group. They also reported that among the parents of the CLP patients, the results were influenced by either gender or educational level (2). In CLP and non-CLP patients and their parents, our study aimed to evaluate the influence of dentofacial attractiveness through the Psychosocial Impact of Dental Aesthetics Questionnaire (PIDAQ) and SWLS, after both were translated and adapted cross-culturally for the regional language, i.e. Malayalam using the schematic given by Sardenberg et al. (25), and the self-rated Aesthetic Component (AC) of the Index of Orthodontic Treatment Need (IOTN-AC). We also sought to ascertain and verify if any relationship existed between the self-rated IOTN-AC scores and the PIDAQ and SWLS scores. Materials and methods This study was conducted over 3 months from October to December 2014 at the Government Dental College, Kottayam, after obtaining prior sanction from the scientific and ethical committee of the institution (M/07/2014/DCK). In this cross-sectional study, a power analysis was performed using a convenience sample of 80 [40 CLP and 40 orthodontic (non-CLP)] patients with an age range of 11–19 years. The sample size was calculated by considering 80 per cent as the power of the study (26). A further sub-division was also done to separate pre-adolescents (age less than 13 years) and adolescents based on the Classification given by Broadribb (27) n=f(α,β)×sd2(μ1−μ2)2. The inclusion criterion for the CLP group was a diagnosis of non-syndromic CLP. Patients in both the CLP and non-CLP groups had no prior orthodontic treatment history and had to be of Kerala origin. The patients were only included after proper informed consent was provided as and when they reported to the outpatient desk at the Department of Orthodontics, Government Dental College, Kottayam, Kerala, India. The CLP patients were usually referred from the Department of Plastic Surgery, Government Medical College, Kottayam and Alappuzha, Kerala, and the Department of Oral and Maxillofacial Surgery, Government Dental College, Kottayam whereas the non-CLP group consisted of regular patients who had consulted for routine orthodontic interventions for various malocclusions. Once informed consent was obtained, all patients were provided with the PIDAQ and SWLS questionnaires, along with a basic data sheet to record their age, sex, socioeconomic status, and other demographic data. They filled in the questionnaires in the waiting room of the post-graduate clinic of the Department of Orthodontics. In both groups, the patients and their parents individually graded their malocclusion by using the IOTN-AC grading chart. Psychosocial impact of dental aesthetics questionnaire (PIDAQ) A psychometric instrument comprising 23 items was used for assessing the orthodontic-oriented traits of QoL, which mainly consisted of four domains: dental self-confidence (DSC; six items), social impact (SI; eight items), psychological impact (PI; six items), and aesthetic concern (ASC; three items). The validity and reliability of PIDAQ have been previously tested (28). The subjects rated the positive or negative impact of dental aesthetics on a Likert scale ranging from 0 to 4 (0 indicated not at all; 1, a little; 2, somewhat; 3, strongly; and 4, very strongly). To ensure that the scoring pattern was in the same direction for all domains, for the DSC items, which scored a positive impact response, the scores were inverted to create a constant and reliable degree of impacts, without hampering the validity of the questionnaire. For adequate measurement of the psychosocial impact, the PIDAQ was translated and cross-culturally adapted into the regional language (Malayalam) according to the schematic followed by Sardenberg et al. (25) in their paper where they translated and validated the Brazilian version of PIDAQ. The process involved two translations from separate blinded translators and back-translations of the original questionnaire in English to Malayalam, finally culminating in a version that comprised the segments that best reflected the original questionnaire after semantic and linguistic appraisal. Testing the reliability of this questionnaire revealed Cronbach’s α values of 0.85–0.91, according to an unpublished initial pilot study of 50 patients and later of 379 subjects, which was conducted by the authors to test the reliability and validity (construct and criterion) of the translated questionnaire. This was consistent with the scales provided by Klages et al. (28) and Shek et al. (29). An overall total PIDAQ score was obtained by summation of the scores of all the items, and the domain scores were obtained by summing the item scores in each domain. Satisfaction with Life Scale (SWLS) As shown by Cochrane and Slade (30), SWLS evaluates subjective wellness in CLP patients. They demonstrated that SWLS has a decent 2-month test–retest internal consistency and reliability (Cronbach’s α =0.87). Biswas-Diener and Diener (31) tested this questionnaire in Calcutta slums. Furthermore, since the responses of pre-adolescents and adolescents may vary, a previously validated questionnaire which was modified for children was also used (32). Because the native language spoken in these two areas differs, this questionnaire was also cross-culturally adapted and pilot-tested in the local language, following which it was then applied to the study subjects. The patients in both groups answered to a seven-point Likert-type scale (ranging from ‘strongly disagree’ to ‘strongly agree’), and the following algorithm was employed to categorize the patients into different grades. A high degree of life satisfaction was indicated when the total score was 30–35, moderate life satisfaction when the score was 18–29, and low life satisfaction when the score was 5–17. Index of orthodontic treatment-aesthetic component (IOTN-AC) (33) The patients and their parents were individually presented with 10 coloured, anterior teeth photos showing varying grades of malocclusion and separately were asked to point out the grade (1–10) of the photograph that most resembled their own or their child’s dentition. No time limit was set for the self-rating of IOTN-AC. The IOTN-AC (33) grades were then used for subject grouping as follows: IOTN-AC score of 1 = first group IOTN-AC score of 2 = second group IOTN-AC score of 3 = third group IOTN-AC scores of 4–10 = fourth group (4+) The rationale for this grouping was that any grading beyond 4 would fall under the moderate-to-severe treatment need category which was the prime focus group of the study; hence this grouping was performed, to simplify the statistics and calculations. Statistical analysis All data were analysed using SPSS version 20.0 for Windows (SPSS Inc., Chicago, Illinois, USA). Descriptive statistics of the PIDAQ, SWLS, and IOTN-AC scores were obtained. Kruskal–Wallis ANOVA and Spearman correlation coefficient (two-tailed) were used to test for the presence of any differences in the mean/median of the responses between the two groups (CLP and Non-CLP; pre-adolescents and adolescents) and for any correlation among the scales, respectively; independent t-test was used to check for any gender differences. Values were considered statistically significant if P < 0.05. Results General descriptive data Age and gender distribution The age of the CLP patients ranged from 11 to 19 years, with the greatest number of respondents aged 13 years (20%), followed by those aged 11 years (15%), 12 years (15%), 15 years (15%); 10 years (10%), and 19 years (10%); the remaining 15 per cent were equally represented by the 14-, 17-, and 18-year age groups. The mean age for the CLP group was 14.2 ± 3.6 years, and the CLP group had equal gender distribution, i.e. 20 males and 20 females. The age of the non-CLP patients ranged from 12 to 19 years, with the greatest number of respondents aged 13 years (30%), followed by those aged 14 years (25%), 12 years (10%), 15 years (10%), and 16 years (10%); the remaining 15 per cent were equally represented by the 17-, 18-, and 19-year age groups. The mean age for the non-CLP group was 14.40 ± 1.90 years, and the non-CLP group also had equal gender distribution, i.e. 20 males and 20 females. Both groups had an equal number of pre-adolescents and adolescents as well i.e. 20 in each group. All subjects were either in high school or had received an education at the high school level, and the subjects in the 18- and 19-year age groups were college-going students. Socioeconomic status The modified Kuppuswamy scale (which periodically changes to adjust for inflation) was used to assess the socioeconomic status (34). Kruskal–Wallis ANOVA showed no significant differences in the responses between the two groups based on socio-economic status. Psychosocial impact of dental aesthetics questionnaire The descriptive distribution of PIDAQ scores for the CLP and non-CLP groups is listed in Table 1. In the CLP group, the DSC scores were highest and lowest for patients Classifying themselves as IOTN-AC grade 4 and above (mean score 16.0) and grade 1 (mean score of 8.0 because of the scoring reversal described in the methodology), respectively. In the non-CLP group, peak DSC scores were observed for those Classifying themselves as IOTN-AC grade 4 and above (mean score 22.0) and vice-versa for those Classifying themselves as grade 1 (mean score 6.50). Table 1. Descriptive distribution of PIDAQ, SWLS scores based on IOTN-AC scoring Group 1 Group 2 Psychological trait CLP group patients (N = 40) Non-CLP group patients (N = 40) Psychological trait CLP group patients (N = 40) Non-CLP group patients (N = 40) Mean ± SD Mean ± SD Mean ± SD Mean ± SD Dental self-confidence 8.00 ± 0.0 6.50 ± 0.0 Dental self-confidence 12.33 ± 8.31 12.00 ± 3.109 Social impact 12.00 ± 0.0 11.00 ± 0.0 Social impact 13.73 ± 12.423 10.71 ± 4.992 Psychosocial impact 13.00 ± 0.0 5.00 ± 0.0 Psychosocial impact 13.00 ± 9.165 14.00 ± 7.165 Aesthetic concern* 7.00 ± 0.0 3.00 ± 0.0 Aesthetic concern* 7.18 ± 5.686 6.50 ± 1.00 PIDAQ total 40.00 ± 0.0 21.00 ± 0.0 PIDAQ Total 48.33 ± 31.44 47.71 ± 9.77 Life satisfaction Total (category) 26.00 ± 0.0 (2) 27.00 ± 0.0 (2) Life satisfaction total (category) 26.33 ± 3.724 (2) 25.00 ± 3.11 (2) Group 3 Group 4+ Psychological trait CLP group patients (N = 40) Non-CLP group patients (N = 40) Psychological trait CLP group patients (N = 40) Non-CLP group patients (N = 40) Mean ± SD Mean ± SD Mean ± SD Mean ± SD Dental self-confidence 15.90 ± 6.92 13.14 ± 8.69 Dental self-confidence 16.00 ± 7.25 22.00 ± 1.71 Social impact 14.00 ± 6.595 11.75 ± 5.936 Social impact 15.67 ± 9.067 14.63 ± 6.989 Psychosocial impact 14.40 ± 4.393 14.50 ± 7.141 Psychosocial impact 15.45 ± 5.027 15.00 ± 6.568 Aesthetic concern* 7.33 ± 4.561 9.25 ± 2.116 Aesthetic concern* 7.40 ± 4.600 9.86 ± 2.915 PIDAQ total 49.8 ± 18.01 50.75 ± 14.48 PIDAQ Total 52.87 ± 17.58 60.37 ± 12.16 Life satisfaction total (category) 28.20 ± 2.44 (2) 25.71 ± 3.583 (2) Life satisfaction total (category) 26.18 ± 4.316 (2) 22.25 ± 4.37 (2) Group 1 Group 2 Psychological trait CLP group patients (N = 40) Non-CLP group patients (N = 40) Psychological trait CLP group patients (N = 40) Non-CLP group patients (N = 40) Mean ± SD Mean ± SD Mean ± SD Mean ± SD Dental self-confidence 8.00 ± 0.0 6.50 ± 0.0 Dental self-confidence 12.33 ± 8.31 12.00 ± 3.109 Social impact 12.00 ± 0.0 11.00 ± 0.0 Social impact 13.73 ± 12.423 10.71 ± 4.992 Psychosocial impact 13.00 ± 0.0 5.00 ± 0.0 Psychosocial impact 13.00 ± 9.165 14.00 ± 7.165 Aesthetic concern* 7.00 ± 0.0 3.00 ± 0.0 Aesthetic concern* 7.18 ± 5.686 6.50 ± 1.00 PIDAQ total 40.00 ± 0.0 21.00 ± 0.0 PIDAQ Total 48.33 ± 31.44 47.71 ± 9.77 Life satisfaction Total (category) 26.00 ± 0.0 (2) 27.00 ± 0.0 (2) Life satisfaction total (category) 26.33 ± 3.724 (2) 25.00 ± 3.11 (2) Group 3 Group 4+ Psychological trait CLP group patients (N = 40) Non-CLP group patients (N = 40) Psychological trait CLP group patients (N = 40) Non-CLP group patients (N = 40) Mean ± SD Mean ± SD Mean ± SD Mean ± SD Dental self-confidence 15.90 ± 6.92 13.14 ± 8.69 Dental self-confidence 16.00 ± 7.25 22.00 ± 1.71 Social impact 14.00 ± 6.595 11.75 ± 5.936 Social impact 15.67 ± 9.067 14.63 ± 6.989 Psychosocial impact 14.40 ± 4.393 14.50 ± 7.141 Psychosocial impact 15.45 ± 5.027 15.00 ± 6.568 Aesthetic concern* 7.33 ± 4.561 9.25 ± 2.116 Aesthetic concern* 7.40 ± 4.600 9.86 ± 2.915 PIDAQ total 49.8 ± 18.01 50.75 ± 14.48 PIDAQ Total 52.87 ± 17.58 60.37 ± 12.16 Life satisfaction total (category) 28.20 ± 2.44 (2) 25.71 ± 3.583 (2) Life satisfaction total (category) 26.18 ± 4.316 (2) 22.25 ± 4.37 (2) *Statistically significant difference (P < 0.05). View Large Table 1. Descriptive distribution of PIDAQ, SWLS scores based on IOTN-AC scoring Group 1 Group 2 Psychological trait CLP group patients (N = 40) Non-CLP group patients (N = 40) Psychological trait CLP group patients (N = 40) Non-CLP group patients (N = 40) Mean ± SD Mean ± SD Mean ± SD Mean ± SD Dental self-confidence 8.00 ± 0.0 6.50 ± 0.0 Dental self-confidence 12.33 ± 8.31 12.00 ± 3.109 Social impact 12.00 ± 0.0 11.00 ± 0.0 Social impact 13.73 ± 12.423 10.71 ± 4.992 Psychosocial impact 13.00 ± 0.0 5.00 ± 0.0 Psychosocial impact 13.00 ± 9.165 14.00 ± 7.165 Aesthetic concern* 7.00 ± 0.0 3.00 ± 0.0 Aesthetic concern* 7.18 ± 5.686 6.50 ± 1.00 PIDAQ total 40.00 ± 0.0 21.00 ± 0.0 PIDAQ Total 48.33 ± 31.44 47.71 ± 9.77 Life satisfaction Total (category) 26.00 ± 0.0 (2) 27.00 ± 0.0 (2) Life satisfaction total (category) 26.33 ± 3.724 (2) 25.00 ± 3.11 (2) Group 3 Group 4+ Psychological trait CLP group patients (N = 40) Non-CLP group patients (N = 40) Psychological trait CLP group patients (N = 40) Non-CLP group patients (N = 40) Mean ± SD Mean ± SD Mean ± SD Mean ± SD Dental self-confidence 15.90 ± 6.92 13.14 ± 8.69 Dental self-confidence 16.00 ± 7.25 22.00 ± 1.71 Social impact 14.00 ± 6.595 11.75 ± 5.936 Social impact 15.67 ± 9.067 14.63 ± 6.989 Psychosocial impact 14.40 ± 4.393 14.50 ± 7.141 Psychosocial impact 15.45 ± 5.027 15.00 ± 6.568 Aesthetic concern* 7.33 ± 4.561 9.25 ± 2.116 Aesthetic concern* 7.40 ± 4.600 9.86 ± 2.915 PIDAQ total 49.8 ± 18.01 50.75 ± 14.48 PIDAQ Total 52.87 ± 17.58 60.37 ± 12.16 Life satisfaction total (category) 28.20 ± 2.44 (2) 25.71 ± 3.583 (2) Life satisfaction total (category) 26.18 ± 4.316 (2) 22.25 ± 4.37 (2) Group 1 Group 2 Psychological trait CLP group patients (N = 40) Non-CLP group patients (N = 40) Psychological trait CLP group patients (N = 40) Non-CLP group patients (N = 40) Mean ± SD Mean ± SD Mean ± SD Mean ± SD Dental self-confidence 8.00 ± 0.0 6.50 ± 0.0 Dental self-confidence 12.33 ± 8.31 12.00 ± 3.109 Social impact 12.00 ± 0.0 11.00 ± 0.0 Social impact 13.73 ± 12.423 10.71 ± 4.992 Psychosocial impact 13.00 ± 0.0 5.00 ± 0.0 Psychosocial impact 13.00 ± 9.165 14.00 ± 7.165 Aesthetic concern* 7.00 ± 0.0 3.00 ± 0.0 Aesthetic concern* 7.18 ± 5.686 6.50 ± 1.00 PIDAQ total 40.00 ± 0.0 21.00 ± 0.0 PIDAQ Total 48.33 ± 31.44 47.71 ± 9.77 Life satisfaction Total (category) 26.00 ± 0.0 (2) 27.00 ± 0.0 (2) Life satisfaction total (category) 26.33 ± 3.724 (2) 25.00 ± 3.11 (2) Group 3 Group 4+ Psychological trait CLP group patients (N = 40) Non-CLP group patients (N = 40) Psychological trait CLP group patients (N = 40) Non-CLP group patients (N = 40) Mean ± SD Mean ± SD Mean ± SD Mean ± SD Dental self-confidence 15.90 ± 6.92 13.14 ± 8.69 Dental self-confidence 16.00 ± 7.25 22.00 ± 1.71 Social impact 14.00 ± 6.595 11.75 ± 5.936 Social impact 15.67 ± 9.067 14.63 ± 6.989 Psychosocial impact 14.40 ± 4.393 14.50 ± 7.141 Psychosocial impact 15.45 ± 5.027 15.00 ± 6.568 Aesthetic concern* 7.33 ± 4.561 9.25 ± 2.116 Aesthetic concern* 7.40 ± 4.600 9.86 ± 2.915 PIDAQ total 49.8 ± 18.01 50.75 ± 14.48 PIDAQ Total 52.87 ± 17.58 60.37 ± 12.16 Life satisfaction total (category) 28.20 ± 2.44 (2) 25.71 ± 3.583 (2) Life satisfaction total (category) 26.18 ± 4.316 (2) 22.25 ± 4.37 (2) *Statistically significant difference (P < 0.05). View Large Similarly, in the CLP group, the SI (mean score 15.67), PI (mean score, 15.45) and ASC (mean score 7.4) scores were highest and lowest in patients categorizing themselves as IOTN-AC grade 4+ and grade 1 (SI: mean score 12.0; PI: mean score 13.0; ASC: mean score 7.0), respectively. In the non-CLP group, a similar pattern was noted for the SI (mean score 14.63), PI (mean score 15.00), and ASC (mean score 9.86) scores, with the maximum values observed for IOTN-AC 4+ patients and the minimum for grade 1 patients (SI: mean score, 1.0; PI: mean score 5.0; ASC: mean score 3.0; Table 1). Regarding the patients’ PIDAQ scores, the CLP group had a mean score of 44.5 (SD 15.1), and the non-CLP group had a mean score of 56.7 (SD 13.4), the difference of which was not statistically significant. Statistically significant differences were observed in the parent AC scores between the two groups (P < 0.03) and in the ASC domain of the PIDAQ scores between the two groups (P < 0.02; Tables 1 and 2). No significant gender difference was observed in the scoring pattern of the PIDAQ. Adolescence status also showed no difference in the scoring pattern of PIDAQ in the non-CLP group, whereas the CLP group showed a lower scoring pattern in the DSC and SI sub-parts of PIDAQ with the adolescent group scoring lower in both sub-parts respectively (P < 0.05). Table 2. Kruskal–Wallis ANOVA comparing the responses in PIDAQ, SWLS, and IOTN-AC for both groups Parameter Test statistic Degree of freedom Significance Dental self-confidence 1.497 1 0.221 Social impact 0.388 1 0.533 Psychosocial impact 0.166 1 0.684 Aesthetic concern 29.911 1 0.02* PIDAQ total 0.477 1 0.490 Life satisfaction category 0.125 1 0.724 Patient’s AC category 0.666 1 0.414 Parent’s AC category 7.39 1 0.03* Parameter Test statistic Degree of freedom Significance Dental self-confidence 1.497 1 0.221 Social impact 0.388 1 0.533 Psychosocial impact 0.166 1 0.684 Aesthetic concern 29.911 1 0.02* PIDAQ total 0.477 1 0.490 Life satisfaction category 0.125 1 0.724 Patient’s AC category 0.666 1 0.414 Parent’s AC category 7.39 1 0.03* *P ≤ 0.05. View Large Table 2. Kruskal–Wallis ANOVA comparing the responses in PIDAQ, SWLS, and IOTN-AC for both groups Parameter Test statistic Degree of freedom Significance Dental self-confidence 1.497 1 0.221 Social impact 0.388 1 0.533 Psychosocial impact 0.166 1 0.684 Aesthetic concern 29.911 1 0.02* PIDAQ total 0.477 1 0.490 Life satisfaction category 0.125 1 0.724 Patient’s AC category 0.666 1 0.414 Parent’s AC category 7.39 1 0.03* Parameter Test statistic Degree of freedom Significance Dental self-confidence 1.497 1 0.221 Social impact 0.388 1 0.533 Psychosocial impact 0.166 1 0.684 Aesthetic concern 29.911 1 0.02* PIDAQ total 0.477 1 0.490 Life satisfaction category 0.125 1 0.724 Patient’s AC category 0.666 1 0.414 Parent’s AC category 7.39 1 0.03* *P ≤ 0.05. View Large Satisfaction with life scale Both groups had comparable life satisfaction scores, which are categorized as moderate in the CLP (mean 26.7; SD, 3.78) and non-CLP (mean 24.25; SD, 4.08) groups, with no significant gender differences between them (Table 1). Kruskal–Wallis ANOVA showed no significant distribution patterns for the scores of SWLS and PIDAQ. Adolescent status also showed no significant difference in scoring pattern. Index of orthodontic treatment-aesthetic component The descriptive distribution of the (patients’ and parents’) IOTN-AC scores of both groups have been summarized in Table 2. In the CLP and non-CLP groups, the mean IOTN-AC score of the patients was 4.90 (SD, 2.78) and 3.75 (SD, 1.94), respectively, and the mean parent score was 7.90 (SD, 2.29) and 5.80 (SD, 2.14), respectively. This difference in parental score was statistically significant. A statistically significant difference in the parental scores was also observed when the groups were assessed according to adolescent status, with the adolescent group’s parents being more critical of their ward’s malocclusion (P < 0.05). Correlations The IOTN-AC scores of the patients and parents in both groups were compared with their SWLS total score, using bivariate analysis (Spearman’s correlation coefficient; Table 3). The patient and parent AC scores showed a statistically significant (P < 0.05) correlation of 0.586 for the CLP group, and the PIDAQ total scores showed statistically significant (P < 0.05) correlations with the patients’ AC scores (0.504) and life satisfaction total score (−0.445) for the non-CLP group. Table 3. Correlation table between IOTN-AC, SWLS, and PIDAQ scores for both groups CLP group (N = 40) Non-CLP group (N = 40) Patients AC grade Life satisfaction total Parents AC PIDAQ total Patients AC grade Life satisfaction total Parents AC PIDAQ total Spearman’s rho Patients AC grade Correlation Coefficient 1 −0.048 0.586* 0.137 1 −0.346 0.205 0.504* Sig. (two-tailed) 0.768 0.000* 0.399 0.029 0.205 0.001* Life satisfaction total Correlation Coefficient −0.048 1 0.044 0.043 −0.346 1 0.202 −0.445* Sig. (two-tailed) 0.768 0.790 0.793 0.029 0.211 0.004* Parent’s AC Correlation Coefficient 0.586 −0.048 1 0.125 0.205 0.202 1 −0.298 Sig. (two-tailed) 0.000 0.768 0.442 0.205 0.211 0.071 PIDAQ total Correlation Coefficient 0.137 0.043 0.125 1 0.504* −0.445* −0.298 1 Sig. (two-tailed) 0.399 0.793 0.442 0.001* 0.004* 0.071 CLP group (N = 40) Non-CLP group (N = 40) Patients AC grade Life satisfaction total Parents AC PIDAQ total Patients AC grade Life satisfaction total Parents AC PIDAQ total Spearman’s rho Patients AC grade Correlation Coefficient 1 −0.048 0.586* 0.137 1 −0.346 0.205 0.504* Sig. (two-tailed) 0.768 0.000* 0.399 0.029 0.205 0.001* Life satisfaction total Correlation Coefficient −0.048 1 0.044 0.043 −0.346 1 0.202 −0.445* Sig. (two-tailed) 0.768 0.790 0.793 0.029 0.211 0.004* Parent’s AC Correlation Coefficient 0.586 −0.048 1 0.125 0.205 0.202 1 −0.298 Sig. (two-tailed) 0.000 0.768 0.442 0.205 0.211 0.071 PIDAQ total Correlation Coefficient 0.137 0.043 0.125 1 0.504* −0.445* −0.298 1 Sig. (two-tailed) 0.399 0.793 0.442 0.001* 0.004* 0.071 *Statistically significant (P < 0.05) (two-tailed). View Large Table 3. Correlation table between IOTN-AC, SWLS, and PIDAQ scores for both groups CLP group (N = 40) Non-CLP group (N = 40) Patients AC grade Life satisfaction total Parents AC PIDAQ total Patients AC grade Life satisfaction total Parents AC PIDAQ total Spearman’s rho Patients AC grade Correlation Coefficient 1 −0.048 0.586* 0.137 1 −0.346 0.205 0.504* Sig. (two-tailed) 0.768 0.000* 0.399 0.029 0.205 0.001* Life satisfaction total Correlation Coefficient −0.048 1 0.044 0.043 −0.346 1 0.202 −0.445* Sig. (two-tailed) 0.768 0.790 0.793 0.029 0.211 0.004* Parent’s AC Correlation Coefficient 0.586 −0.048 1 0.125 0.205 0.202 1 −0.298 Sig. (two-tailed) 0.000 0.768 0.442 0.205 0.211 0.071 PIDAQ total Correlation Coefficient 0.137 0.043 0.125 1 0.504* −0.445* −0.298 1 Sig. (two-tailed) 0.399 0.793 0.442 0.001* 0.004* 0.071 CLP group (N = 40) Non-CLP group (N = 40) Patients AC grade Life satisfaction total Parents AC PIDAQ total Patients AC grade Life satisfaction total Parents AC PIDAQ total Spearman’s rho Patients AC grade Correlation Coefficient 1 −0.048 0.586* 0.137 1 −0.346 0.205 0.504* Sig. (two-tailed) 0.768 0.000* 0.399 0.029 0.205 0.001* Life satisfaction total Correlation Coefficient −0.048 1 0.044 0.043 −0.346 1 0.202 −0.445* Sig. (two-tailed) 0.768 0.790 0.793 0.029 0.211 0.004* Parent’s AC Correlation Coefficient 0.586 −0.048 1 0.125 0.205 0.202 1 −0.298 Sig. (two-tailed) 0.000 0.768 0.442 0.205 0.211 0.071 PIDAQ total Correlation Coefficient 0.137 0.043 0.125 1 0.504* −0.445* −0.298 1 Sig. (two-tailed) 0.399 0.793 0.442 0.001* 0.004* 0.071 *Statistically significant (P < 0.05) (two-tailed). View Large Discussion A limited number of studies have attempted to identify a relationship between subjects categorized in the groups of ‘marginal-to-severe’ treatment need on the basis of their self-rated IOTN-AC scores (4). According to the literature, no studies so far evaluated this relation in the South Indian (Central Kerala) population nor have they attempted to study the difference between CLP and non-CLP patients with the inclusion of their parents’ perspectives. Although the ethical appropriateness of parents judging their children (who in this study were as old as 19 years) is debatable, during the history taking, we constantly observed that the parents were more anxious and concerned about the treatment plan than were their children. In addition, considering the major prevalence of arranged marriages in this region, the parents are often and usually more concerned about their child’s appearance because, in their opinion, this would affect the demand for suitors for their ward/child as even older literature has cited the importance of facial attractiveness in being selected and deemed as a ‘better mate’ (35–40). This scoring pattern difference was highlighted in the study by the parental score i.e. their perception worsened as their ward moved towards adolescence and adulthood in both groups. Therefore, it is pertinent that parents are counselled as well as the patient, especially if the patient is of adolescent age. Psychosocial impact of dental aesthetics questionnaire Comparison of the scores of the four PIDAQ domains, DSC, SI, PI, and ASC, with the IOTN-AC grade 1 to 4+ scores, which were given by the subjects and parents, highlights the clear psychosocial impact of sub-normal/altered dental aesthetics, and this was evident in both groups (Table 1). The DSC domain deals with the satisfaction/dissatisfaction with one’s own dentition appearance, and it indirectly assesses how an individual’s self-image is affected by their appearance, taking into consideration how this perceived notion of facial attractiveness contributes to one’s self-concept and self-esteem (2, 41, 42). The previous statement was highlighted by our results, which showed decreasing DSC scores when the study subjects’ perceived their dentofacial aesthetics as sub-normal/diminished, according to IOTN-AC. This was in concurrence with the findings of Klages et al. (28), who stated that well-aligned teeth (marked by low IOTN-AC scores) indicate more favourable oral-health attitudes and greater satisfaction with dentofacial attractiveness, culminating in better self-concept. Both groups had similar scoring patterns and trends, indicating that the DSC scores were equally affected in the two groups, without any remarkable difference. SI forecasts the difficulties faced in public situations because of a self-perceived unfavourable dental appearance. Individuals experience positive peer interactions and evaluations more often if they are socially considered to be more attractive (41, 42). Our study revealed the impact of this parameter and the negative influence of social assessment of attractiveness by peers, without any notable difference between the two groups. The phenomenon of ‘social-comparison’, where aesthetic-based self-concept is influenced to such a degree that it can end up as a social handicap of sorts, could explain the findings of this study (41). In addition, Onyeaso et al. (42) stated that approximately 40 per cent of their study subjects had low or restricted confidence during public interactions, such as laughing, because of their abnormal dental features. They also reported depression in 27 per cent of their subjects, which was attributed to poor dentofacial aesthetics. However, in the CLP group, the scoring pattern decreased as the subjects matured towards adolescence indicating the greater impact of dentofacial attractiveness in their self-confidence and the associated SI it had in peer-to-peer interaction. This may affect their chances in maintaining a normal social posture in various aspects like employment, dating etc. and hence this finding should be investigated further to yield some light on the same. Furthermore, the associated SI of their condition should be looked into especially during the treatment planning process. This may include the choice and type of mechanotherapy (metal versus ceramic brackets, lingual appliances, clear aligners etc) especially with respect to the appliance’s appearance and subsequent duration of wear. Self-comparison with others leading to one’s own dissatisfaction/lowliness is assessed through PI. To quote Tung and Kiyak (41), ‘Researchers have consistently found that self-concept is related more to the individual’s perceptions of others’ evaluations than to objective evaluations by others’. In this study, high and low AC scoring grades were associated with reduced wellness psychologically when the dental aesthetics gradually declined. Similar to the other domains, no significant differences were noted between the two groups, indicating similar psychological patterns. The fourth domain of PIDAQ (i.e. ASC) comprises statements towards one’s disapproval of one’s own dental aesthetics in mirror reflections and pictures (static or motion). This explains why aesthetic correction is commonly one of the main motivations for seeking orthodontic correction. Our results showed a statistically significant difference in responses between the two groups (Tables 1 and 2), indicating that this motivation is higher among CLP patients. Because a comparative study of CLP and non-CLP patients have not been performed using PIDAQ, these findings could shed some light on the psychological profile of both groups. A greater treatment need for malocclusion, which is self-perceived in ascending grades of malocclusion, was observed by Mandall et al. (43), who stated that those who are teased about their teeth actively seek orthodontic treatment. While it is deemed appropriate to use a questionnaire like COHIP, since the study sample has an age range which includes pre-adolescents as well as adolescents, a wider age ranged and validated questionnaire like PIDAQ could serve and measure the intended parameters better. Satisfaction with life scale Both groups had comparable life satisfaction scores, which were categorized as moderate; this finding is consistent with previous data on CLP and routine patients (2). No significant differences were observed between the two groups as independent t-tests showed very similar scores for both groups, with no differences for gender and socioeconomic status. Index of orthodontic treatment need-aesthetic component No relationship was observed between parents’ AC rating and PIDAQ scores; this coupled with the fact that parents rated the malocclusion more critically especially as patients progressed towards adolescence and adulthood, indicates that patients’ scores should serve as a better baseline to assess the psychosocial impact of their malocclusion. In addition, excessively anxious or critical parents must be carefully managed and counselled, if necessary, so that parental psychological support to the patients, especially CLP patients, can be adequately provided during treatment. Interestingly, the CLP patients expressed some difficulty in grading themselves according to the original IOTN AC grading chart. This difficulty arose from the fact that no pictures of an anterior crossbite or of a Class III dentition were provided. Given the fact that the IOTN has been tool most widely used in the literature to screen patients (which allows comparison with findings from other studies), this coincidental finding could be further investigated to modify the existing AC grading chart to make it more suitable for CLP patients. Correlations In the CLP group, a positive and significant correlation of 0.586 was observed between the AC scores of patients and parents (P < 0.05) i.e. approximately half the time, the perceptions of the parent and the patients differed. In the non-CLP group, statistically significant (P < 0.05) correlations were observed between the PIDAQ total scores and patients’ AC scores (0.504) and between the PIDAQ scores and life satisfaction total scores (−0.445). This indicates the potential impact that altered dentofacial aesthetics has on an individual’s social and mental well-being. Also as previously mentioned, the CLP group had some difficulty in relating to the IOTN-AC scoring chart; this could explain the significant correlation between the parental and patient scoring, as this was not observed in the non-CLP group. Moreover, the PIDAQ and patient AC scores showed significant correlation, which is in line with previous findings (5, 28). Regarding the non-CLP group, to the best of our knowledge, few studies have examined the correlation of SWLS and PIDAQ scores (2); however, the significant negative correlation between the two indicates the impact of sub-normal/poor dentofacial aesthetics and its potential impact on life satisfaction, even though no significant difference was found between the groups. A larger sample could be fruitful in assessing this unique psychosocial correlation between these two scales. Limitations and future scope The results show a decisive pattern indicating that the impact of malocclusion (psychosocial) has an inverse relationship with IOTN-AC grade and overall psychosocial wellness. Additional studies with a larger sample may be needed to corroborate our findings because, in the present study, a sample of 80 was assessed, which may not provide adequate representation. Future studies could evaluate additional parameters such as coping mechanisms for stress, the anxiety levels of patients and parents, and the influence of age and education on psychosocial development. The questionnaires used in this study, namely SWLS and PIDAQ, are both generic. A future study using a condition-specific questionnaire (specific to clefts) could detect minor but important psychosocial aspects with regard to the targeted group (i.e. CLP). Moreover, a study could also be attempted to distinguish the responses between unilateral and bilateral cleft patients as well. The psychological needs of the patients must be considered and catered to during treatment planning, thereby facilitating more thorough rehabilitation. Additional studies involving a larger sample and other instruments (subjective or objective), could be conducted to substantiate these results. Conclusion This study focused on evaluating the differences among the self- concept, life satisfaction, and psychosocial impact of malocclusion in CLP and non-CLP orthodontic patients and their parents. No difference was observed in life satisfaction between the two groups as estimated using the SWLS (normal and that adapted for pre-adolescents). The parents of both groups rated the malocclusion more critically than did the patients and sometimes may require counselling and appropriate management with a more critical scoring trend as the patient’s age moves towards adolescence and adulthood. Major differences were observed regarding psychosocial wellbeing, with the CLP group rating themselves with a lower score in relation to ASC. The CLP group adolescents also scored lower in the DSC and SI sub-parts compared to the pre-adolescent CLP group. This indicates that the self-assessment of one’s own attractiveness, especially for dentofacial irregularities can contribute significantly in ascertaining the need for treatment, its associated psychosocial impact and the severity of the afflicted condition. Funding The study received no external funding to conduct this research through any of the authors involved. Conflict of Interest None to declare. Acknowledgements This manuscript was presented at 4th Virtual World Dental Congress held online from May 14th to 16th 2014 and awarded the first place. This manuscript was awarded the 750$ Charles Schultz Research Scholar Award at the Annual Session of the American Association of Orthodontists (AAO) held at San Francisco from May 15th to 19th 2015. This manuscript has been selected and accepted for presentation in International Cleft Congress 2017 in the ORAL FREE PAPER CATEGORY. References 1. Mossey , P. and Little , J . ( 2009 ) Addressing the challenges of cleft lip and palate research in India . Indian Journal of Plastic Surgery , 42 ( Suppl ), S9 – S18 . Google Scholar CrossRef Search ADS 2. Cheung , L.K. , Loh , J.S. and Ho , S.M . ( 2007 ) Psychological profile of Chinese with cleft lip and palate deformities . The Cleft Palate Craniofacial Journal , 44 , 79 – 86 . Google Scholar CrossRef Search ADS 3. Allyn & Bacon . ( 1999 ) Social thought and social behaviour . In Baron , R.A . (ed.), Essentials of psychology . 2nd ed , Pearson Publishing, Massachusetts , pp. 535 – 66 . 4. Bos , A. , Hoogstraten , J. and Prahl-Andersen , B . ( 2003 ) Expectations of treatment and satisfaction with dentofacial appearance in orthodontic patients . American Journal of Orthodontics and Dentofacial Orthopedics , 123 , 127 – 132 . Google Scholar CrossRef Search ADS 5. Delcides , F. de Paula Jr , Nádia , C.M. , Santos , S.E.T. , Nunes , M.F. and Leles , C.R . ( 2009 ) Psychosocial impact of dental esthetics on quality of life in adolescents association with malocclusion, self-image, and oral health–related issues . The Angle Orthodontist , 79 , 1188 – 1193 . Google Scholar CrossRef Search ADS 6. Azuma , S. , Kohzuki , M. , Saeki , S. , Tajima , M. , Igarashi , K. and Sugawara , J . ( 2008 ) Beneficial effects of orthodontic treatment on quality of life in patients with malocclusion . The Tohoku Journal of Experimental Medicine , 214 , 39 – 50 . Google Scholar CrossRef Search ADS 7. Bernabé , E. , Tsakos , G. , Messias de Oliveira , C. and Sheiham , A . ( 2008 ) Impacts on daily performances attributed to malocclusions using the condition-specific feature of the Oral Impacts on Daily Performances Index . The Angle Orthodontist , 78 , 241 – 247 . Google Scholar CrossRef Search ADS 8. Bernabé , E. and Flores-Mir , C . ( 2006 ) Orthodontic treatment need in Peruvian young adults evaluated through dental aesthetic index . The Angle Orthodontist , 76 , 417 – 421 . 9. Hamdan , A.M. , Al-Omari , I.K. and Al-Bitar , Z.B . ( 2007 ) Ranking dental aesthetics and thresholds of treatment need: a comparison between patients, parents, and dentists . European Journal of Orthodontics , 29 , 366 – 371 . Google Scholar CrossRef Search ADS 10. Hamdam , A.M . ( 2004 ) The relationship between patient, parent and clinician perceived need and normative orthodontic treatment need . European Journal of Orthodontics , 26 , 265 – 271 . Google Scholar CrossRef Search ADS 11. Gherunpong , S. , Tsakos , G. and Sheiham , A . ( 2006 ) A socio-dental approach to assessing children’s orthodontic needs . European Journal of Orthodontics , 28 , 393 – 399 . Google Scholar CrossRef Search ADS 12. de Oliveira , C.M. and Sheiham , A . ( 2003 ) The relationship between normative orthodontic treatment need and oral health-related quality of life . Community Dentistry and Oral Epidemiology , 31 , 426 – 436 . Google Scholar CrossRef Search ADS 13. Klages , U. , Bruckner , A. and Zentner , A . ( 2004 ) Dental aesthetics, self-awareness, and oral health-related quality of life in young adults . European Journal of Orthodontics , 26 , 507 – 514 . Google Scholar CrossRef Search ADS 14. Tajima , M. , Kohzuki , M. , Azuma , S. , Saeki , S. , Meguro , M. and Sugawara , J . ( 2007 ) Difference in quality of life according to the severity of malocclusion in Japanese orthodontic patients . The Tohoku Journal of Experimental Medicine , 212 , 71 – 80 . Google Scholar CrossRef Search ADS 15. Phillips , C. and Beal , K.N . ( 2009 ) Self-concept and the perception of facial appearance in children and adolescents seeking orthodontic treatment . The Angle Orthodontist , 79 , 12 – 16 . Google Scholar CrossRef Search ADS 16. Ranganathan , K. , Vercler , C.J. , Warschausky , S.A. , MacEachern , M.P. , Buchman , S.R. and Waljee , J.F . ( 2015 ) Comparative effectiveness studies examining patient-reported outcomes among children with cleft lip and/or palate: a systematic review . Plastic and Reconstructive Surgery , 135 , 198 – 211 . Google Scholar CrossRef Search ADS 17. Eichenberger , M. , Staudt , C.B. , Pandis , N. , Gnoinski , W. and Eliades , T . ( 2014 ) Facial attractiveness of patients with unilateral cleft lip and palate and of controls assessed by laypersons and professionals . European Journal of Orthodontics , 36 , 284 – 289 . Google Scholar CrossRef Search ADS 18. Gkantidis , N. , Papamanou , D.A. , Christou , P. and Topouzelis , N . ( 2013 ) Aesthetic outcome of cleft lip and palate treatment. Perceptions of patients, families, and health professionals compared to the general public . Journal of Cranio-Maxillo-Facial Surgery , 41 , e105 – e110 . Google Scholar CrossRef Search ADS 19. Gkantidis , N. , Papamanou , D.A. , Karamolegkou , M. and Dorotheou , D . ( 2015 ) Esthetic, functional, and everyday life assessment of individuals with cleft lip and/or palate . BioMed Research International , 2015 , 510395 . Google Scholar CrossRef Search ADS 20. Broder , H.L. , Smith , F.B. and Strauss , R.P . ( 1992 ) Habilitation of patients with clefts: parent and child ratings of satisfaction with speech . Cleft Palate Craniofac J , 29 , 262 – 267 . Google Scholar CrossRef Search ADS 21. Turner , S.R. , Rumsey , N. and Sandy , J.R . ( 1998 ) Psychological aspects of cleft lip and palate . European Journal of Orthodontics , 20 , 407 – 415 . Google Scholar CrossRef Search ADS 22. Berscheid , E. and Gangestad , S . ( 1982 ) The social psychological implications of facial physical attractiveness . Clinics in Plastic Surgery , 9 , 289 – 296 . 23. Broder , H.L. and Strauss , R.P . ( 1989 ) Self-concept of early primary school age children with visible or invisible defects . Cleft Palate J , 24 , 158 – 163 . 24. Berk , N.W. , Cooper , M.E. , Liu , Y.E. and Marazita , M.L . ( 2001 ) Social anxiety in Chinese adults with oral-facial clefts . The Cleft Palate-Craniofacial Journal , 38 , 126 – 133 . Google Scholar CrossRef Search ADS 25. Sardenberg , F. , Oliveira , A.C. , Paiva , S.M. , Auad , S.M. and Vale , M.P . ( 2011 ) Validity and reliability of the Brazilian version of the psychosocial impact of dental aesthetics questionnaire . European Journal of Orthodontics , 33 , 270 – 275 . Google Scholar CrossRef Search ADS 26. Pandis , N. , Polychronopoulou , A. and Eliades , T . ( 2011 ) Sample size estimation: an overview with applications to orthodontic clinical trial designs . American Journal of Orthodontics and Dentofacial Orthopedics , 140 , e141 – e146 . Google Scholar CrossRef Search ADS 27. Hartfield N . ( 2008 ) Broadribb’s Introductory Pediatric Nursing . Lippincott Williams & Wilkins , 7th edn , pp. 588 28. Klages , U. , Claus , N. , Wehrbein , H. and Zentner , A . ( 2006 ) Development of a questionnaire for assessment of the psychosocial impact of dental aesthetics in young adults . European Journal of Orthodontics , 28 , 103 – 111 . Google Scholar CrossRef Search ADS 29. Shek DT . ( 1998 ) Adolescent positive mental health and psychological symptoms: a longitudinal study in a Chinese context . Psychologia: Int J Psychol Orient , 41 , 217 – 225 . 30. Cochrane , V.M. and Slade , P . ( 1999 ) Appraisal and coping in adults with cleft lip: associations with well-being and social anxiety . British Journal of Medical Psychology , 72 ( Pt 4 ), 485 – 503 . Google Scholar CrossRef Search ADS 31. Biswas-Diener , D . ( 2001 ) Making the best of a bad situation: satisfaction in the slums of calcutta . Social Indicators Research , 55 , 29 – 352 . Google Scholar CrossRef Search ADS 32. Gadermann , A.M. , Schonert-Reichl , K.A. and Zumbo , B.D . ( 2010 ) Investigating validity evidence of the Satisfaction with Life Scale adapted for Children . Social Indicators Research , 96 , 229 – 247 . Google Scholar CrossRef Search ADS 33. Brook , P.H. and Shaw , W.C . ( 1989 ) The development of an index of orthodontic treatment priority . European Journal of Orthodontics , 11 , 309 – 320 . Google Scholar CrossRef Search ADS 34. Gururaj , M . ( 2014 ) Kuppuswamy’s Socio-Economic Status Scale – a revision of income parameter for 2014 . International Journal of Recent Trends in Science and Technology , 11 , 01 – 02 . Google Scholar CrossRef Search ADS 35. Møller , A.P. and Thornhill , R . ( 1998 ) Bilateral symmetry and sexual selection: a meta-analysis . The American Naturalist , 151 , 174 – 192 . Google Scholar CrossRef Search ADS 36. Elder , G.H. Jr . ( 1969 ) Appearance and education in marriage mobility . American Sociological Review , 34 , 519 – 533 . Google Scholar CrossRef Search ADS 37. Holmes , S.J. and Hatch , C.E . ( 1938 ) Personal appearance as related to scholastic records and marriage selection in college women . Human Biology , 10 , 65 – 76 38. Riggio , R. and Woll , S . ( 1984 ) The role of non-verbal and physical attractiveness in the selection of dating partners . Journal of Social and Personal Relationships , 1 , 347 – 357 . Google Scholar CrossRef Search ADS 39. Berscheid , E. , Dion , K. , Walster , E. and Walster , G.W . ( 1971 ) Physical attractiveness and dating choice: a test of the matching hypothesis . Journal of Experimental Social Psychology , 7 , 173 – 189 . Google Scholar CrossRef Search ADS 40. Little , A.C. , Jones , B.C. and DeBruine , L.M . ( 2011 ) Facial attractiveness: evolutionary based research . Philosophical Transactions of the Royal Society of London Series B: Biological Sciences , 366 , 1638 – 1659 . Google Scholar CrossRef Search ADS 41. Tung , A.W. and Kiyak , H.A . ( 1998 ) Psychological influences on the timing of orthodontic treatment . American Journal of Orthodontics and Dentofacial Orthopedics , 113 , 29 – 39 . Google Scholar CrossRef Search ADS 42. Onyeaso , C.O. , Utomi , I.L. and Ibekwe , T.S . ( 2005 ) Emotional effects of malocclusion in Nigerian orthodontic patients . The Journal of Contemporary Dental Practice , 6 , 64 – 73 . 43. Mandall , N.A. , Wright , J. , Conboy , F. , Kay , E. , Harvey , L. and O’Brien , K.D . ( 2005 ) Index of orthodontic treatment need as a predictor of orthodontic treatment uptake . American Journal of Orthodontics and Dentofacial Orthopedics , 128 , 703 – 707 . Google Scholar CrossRef Search ADS © The Author(s) 2018. Published by Oxford University Press on behalf of the European Orthodontic Society. All rights reserved. For permissions, please email: journals.permissions@oup.com This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/about_us/legal/notices)

Journal

The European Journal of OrthodonticsOxford University Press

Published: Apr 18, 2018

There are no references for this article.

You’re reading a free preview. Subscribe to read the entire article.


DeepDyve is your
personal research library

It’s your single place to instantly
discover and read the research
that matters to you.

Enjoy affordable access to
over 18 million articles from more than
15,000 peer-reviewed journals.

All for just $49/month

Explore the DeepDyve Library

Search

Query the DeepDyve database, plus search all of PubMed and Google Scholar seamlessly

Organize

Save any article or search result from DeepDyve, PubMed, and Google Scholar... all in one place.

Access

Get unlimited, online access to over 18 million full-text articles from more than 15,000 scientific journals.

Your journals are on DeepDyve

Read from thousands of the leading scholarly journals from SpringerNature, Elsevier, Wiley-Blackwell, Oxford University Press and more.

All the latest content is available, no embargo periods.

See the journals in your area

DeepDyve

Freelancer

DeepDyve

Pro

Price

FREE

$49/month
$360/year

Save searches from
Google Scholar,
PubMed

Create lists to
organize your research

Export lists, citations

Read DeepDyve articles

Abstract access only

Unlimited access to over
18 million full-text articles

Print

20 pages / month

PDF Discount

20% off