Revista Adolescência e Saúde

Revista Oficial do Núcleo de Estudos da Saúde do Adolescente / UERJ

NESA Publicação oficial
ISSN: 2177-5281 (Online)

Vol. 14 nº 4 - Oct/Dec - 2017


Páginas 157 a 166

Self-perception of dental aesthetics and its impact on adolescent's life

La autopercepción de la estética dental y su impacto en la vida del adolescente

A autopercepção da estética dental e seu impacto na vida do adolescente

Autores: Aline Cavalcanti da Costa1; Fabrícia Soares Rodrigues2; Mônica Vilela Heimer3

1. Mestrado Hebiatria in the Department of Preventive and Social Dentistry, University of Pernambuco (UPE). Recife, PE, Brazil. Specialization in Orthodontics and Facial Orthopedics by the Military Hospital of Recife Area (HMAR). Recife, PE, Brazil
2. Mestrado Hebiatria in the Department of Preventive and Social Dentistry, University of Pernambuco (UPE). Recife, PE, Brazil. Surgeon-Dentist, Federal University of Pernambuco (UFPE). Recife, PE, Brazil
3. PhD by University of Dundee. Dundee, Scotland. Adjunct Professor, Faculty of Dentistry, University of Pernambuco FOP-UPE. Recife, PE, Brazil

Aline Cavalcanti da Costa
Rua Afonso de Albuquerque Melo, nº 60, Apt. 502, Santana
Recife, PE, Brasil. CEP: 52060-450

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How to cite this article

Keywords: Malocclusion, Esthetics, Dental, self concept, adolescent.
Palabra Clave: Mala oclusión, estética dental, auto-imagen, adolescente.
Descritores: Má oclusão, estética dentária, autoimagem, adolescente.

OBJECTIVE: Analyze the national and international scientific literature on the self-perception of dental aesthetics by adolescents and its impact on their quality of life, self-esteem and satisfaction with appearance.
DATA SOURCE: Integrative literature review of articles indexed in PubMed, Lilacs and Medline and the guiding questions: "does self-perceived dental aesthetics of adolescents correspond to malocclusion observed by professionals in the field?", "Is there an association between orthodontic treatment and the improvement of self-esteem?", and "does the presence of malocclusion have an impact on the quality of life of adolescents or in satisfaction with appearance?".
DATA SYNTHESIS: Adolescents do perceive malocclusion which impacts their emotional well-being, and orthodontic treatment does improve self-esteem and satisfaction with appearance.
CONCLUSION: The perception of malocclusion leads to dissatisfaction with appearance, lower quality of life and lower self-esteem and it should be considered as an important criterion in the diagnosis of orthodontic treatment. Severe malocclusion generates greater self-awareness. However, individuals with low self-esteem tend to perceive more the imperfections even in cases of mild malocclusions. The crowding of anterior jaw and the space between the teeth were the malocclusion features more subjectively perceived.

OBJETIVO: Analizar la producción científica nacional e internacional sobre la autopercepción de la estética dental por los adolescentes y su repercusión en la calidad de vida, autoestima y satisfacción con la apariencia.
FUENTE DE DATOS: Revisión integral de literatura de artículos indexados Pubmed, Lilacs y Medline,  con las preguntas dirigidas "la autopercepción de la estética dental de los adolescentes ¿corresponde a maloclusión observada por profesionales del área?", "¿Existe asociación entre tratamiento de ortodoncia y la mejoría de la autoestima?" y "¿La presencia de maloclusión impacta en la calidad de vida de los adolescentes o en la satisfacción con la apariencia?".
SÍNTESES DE LOS DATOS: Los adolescentes perciben las maloclusiones, las cuales impactan en el bienestar emocional y el tratamiento de ortodoncia mejora la autoestima y la satisfacción con la apariencia.
CONCLUSIÓN: La autopercepción de las maloclusiones lleva a insatisfacción con la apariencia, menor calidad de vida y menor autoestima y debe ser considerada un criterio importante en el diagnóstico de los tratamientos de ortodoncia. Cuanto más severa la maloclusión, mayor la autopercepción negativa. Inclusive, individuos con baja autoestima tienden a percibir más las imperfecciones, mismo en casos de maloclusión leve. El apiñamiento de la región anterior del maxilar y el espacio entre los dientes fueron las características de maloclusión más percibidas subjetivamente.

OBJETIVO: Analisar a produção científica nacional e internacional sobre a autopercepção da estética dental pelos adolescentes e sua repercussão na qualidade de vida, autoestima e satisfação com a aparência.
FONTES DE DADOS: Revisão integrativa da literatura de artigos indexados Pubmed, Lilacs e na Medline e com as perguntas norteadoras "a autopercepção da estética dental dos adolescentes corresponde a maloclusão observada por profissionais da área?", "Existe associação entre tratamento ortodôntico e a melhora da autoestima?" e "A presença de maloclusão impacta na qualidade de vida dos adolescentes ou na satisfação com aparência?".
SÍNTESE DOS DADOS: Os adolescentes percebem as maloclusões, as quais impactam no bem-estar emocional, e o tratamento ortodôntico melhora a autoestima e satisfação com a aparência.
CONCLUSÃO: A autopercepção das maloclusões leva a insatisfação com aparência, menor qualidade de vida e menor autoestima e deve ser considerado um critério importante no diagnóstico dos tratamentos ortodônticos. Quanto mais severa a maloclusão, maior a autopercepção negativa. Todavia, indivíduos com baixa autoestima tendem a perceber mais as imperfeições mesmo em casos de maloclusão leve. O apinhamento da região anterior da maxila e o espaço entre os dentes foram as características da maloclusão mais percebidas subjetivamente.


According to the national survey of oral health1 , 38.8% of Brazilian adolescents present occlusion problems at 12 years of age. In 19.9% ​​of these adolescents, problems are expressed in the mildest form. However, 19.0% have severe or very severe malocclusion, these being the conditions that require more immediate treatment, being a priority in terms of Public Health 1 .

Malocclusions have occupied third place among oral problems in the Brazilian population, but the inclusion of these changes as a public health problem is due not only to their high prevalence but also to the impact on people's quality of life2. In addition to a clinical diagnosis, it is also necessary to consider more subjective factors, since the disease does not only imply the absence of physical well-being. It is important to note that even when this physical well-being is not present, its impact will depend largely on the psychological state of principles and personal and cultural values of the individual3.

In the period of adolescence, physical appearance assumes a significant importance in the construction of personal identity, including the relation with the own body. A variety of social, psychological, cultural and personal factors, influence the self-perception of dental appearance and the search for orthodontic treatment4.

The current concept of health does not allow us to think about the health/disease process without considering the psychosocial aspects. Thus, within a salutogenic conception of Antonovsky's theory, we try to explain why people in similar adverse conditions present different health outcomes. It is not a matter of selecting the strongest individuals from the weakest, but identifying those who have the least psychological resources and who do not believe in their own possibilities of influencing their life and health5.

The salutogenic model is presented as a counterpoint to the pathogenic model and is directly related to health promotion. The principles of salutogenesis have been applied in the development of educational actions aimed at the promotion of health and in the formulation of a theoretical model for the construction of healthy public policies6.

Currently, to measure any intervention in the health area, including oral health care services, such as orthodontics, measures of importance to the patient that reflect their perceptions are necessary, without leaving aside the informational measures for the clinician. Therefore, the subjective indicators have become important tools to be able to capture also the patient's perception about his smile7, and can serve as a criterion in the selection of patients with greater need for treatment in the public service8.

Since self-image is the description that the individual makes of himself, it becomes important to observe two distinct aspects: the descriptive, called self-image or self-perception, and the value, called self-esteem9. When there is perception of an aesthetic deviation in physical appearance, within this description, the impact of such deviation on self-esteem is an important issue in determining the benefits of corrective orthodontic treatment10. The dissatisfaction with the aesthetic appearance has been associated to a discrepancy between the perception of its appearance and the desire related to a pattern11.


To carry out an integrative review of the literature on the self-perception of malocclusions by adolescents.


This study of integrative review of the literature was conducted by the following guiding questions: "Self-perception of adolescents dental aesthetics corresponds to malocclusion observed by professionals in the area (normative)". "Is there an association between orthodontic treatment and improvement of self-esteem?" presence of malocclusion impacts on the quality of life of adolescents or on satisfaction with appearance?".

This review was performed through the analysis of articles published in databases with a large amount of impact research for health (Table 1). The study included articles on the topic of self-perception, malocclusion and need for orthodontic treatment available in the international and national literature indexed in the National Library of Medicine (Pubmed), Latin American Health Sciences Literature (Lilacs) and the Medical Literature Analysis and Retrieval System Online (Medline).

For the refinement of the research, the articles in the English, Portuguese and Spanish languages were defined as inclusion criteria, with the abstracts available in the abovementioned databases, from 2004 to 2015, and covering the age group from 10 to 19 years. We excluded from this selection the studies that were repeated in the databases, studies that were classified as articles of literature review and those that were not presented in an article format, such as guidelines, letters, editorials, theses and dissertations.

As a strategy the search was done using the advanced search form, using the following subject descriptors and logical operators: "Self concept" AND "malocclusion" OR "orthodontic treatment" recognized by the vocabulary MESCH and DESC. In Table 1, you can view the number of articles found in each database.

First, all the titles were read, then the articles that had their abstracts selected (according to the aforementioned criteria) were read in their entirety and analyzed, taking into consideration the target population, study design, sample plan, the methodology used and the results found in the associations between the self-perception of the adolescent and the malocclusion or orthodontic treatment. The table below shows how the articles were selected (Table 2).

The excluded articles presented a different age group than the objective of the present study, they approached self-perception of other parts of the body, did not use any validated instrument of self-perception or addressed the topic of interest, but the objective of the research was not the self-perception of the dental aesthetic by the adolescent.


In order to provide a panoramic view of the studies on malocclusion and self-perception in adolescents, it is shown in Table 3. The studies showed significant correlations between normative and self-perceived malocclusion (MomeniSalehi, 2010), increased dissatisfaction with malocclusion according to the higher severity of the (Peres et al 2008, Tessarollo et al., 2011) and increased age (Phillips and Beal, 2009). Orthodontic treatment of malocclusions has a positive impact on adolescents' quality of life and self-perception of dental aesthetics (Badran 2010, Feu et al., 2012 and Hirvinwn et al., 2012), especially in those with low self-esteem (Agou et al. The presence of malocclusion impacts on psychosocial aspects (Paula et al., 2011) and its correction is more associated with functional than emotional well-being.

Regarding the time distribution, the studies were divided into three periods as follows: 5% from 2004 to 2006; 52% from 2007 to 2010 and 43% from 2011 to date. As for the geographical distribution, 10% of the research was located in the African continent; 20% on the European continent; 25% in Asia and 45% in the Americas. Within the American continent, most of the research was conducted in Brazil (78%).


Some studies have shown a correlation between the need for normative treatment and the adolescent's perception, but this correlation was weak, since the adolescents were less critical about their aesthetic appearance than professionals13,22-24.

The literature suggests that orthodontic treatment may bring some psychosocial benefits, such as improvement of aesthetic perception and reduction of social anxiety4,29. The findings of Feu et al. (2012)15 corroborate this idea because, when comparing three groups of adolescents: no treatment, waiting for orthodontic treatment and at the beginning of an orthodontic treatment, found that, at the beginning, the group under orthodontic treatment had a score of aesthetic self-perception 96 % higher than the untreated group, especially in the first week of treatment. This result probably occurred because at the beginning of treatment malocclusions become more evident, the pain and discomfort with the device are greater, and influence in the increase of the adolescent's dissatisfaction. However, in the final interview, the complaints of the treatment group were 20% lower than the other groups. Corroborating with the aforementioned studies, Hirvinen et al. (2012)24 compared orthodontically treated and untreated adolescents, the former being significantly more satisfied with their dental appearance (P = 0.034).

On the other hand, De Baets et al. (2012)14 found a significant association between need for orthodontic treatment and quality of life related to oral health, and between self-esteem and quality of life. However, there was no evidence that self-esteem influences the relationship between quality of life and need for orthodontic treatment.

Nammontri et al. (2013)28 conducted a school-based intervention to improve psychosocial factors related to oral health and the results showed that there was an improvement in the perception of dental aesthetics and quality of life related to oral health in the intervention group stability of the results obtained.

The regression analysis of the study with Canadian adolescents of Agou et al. (2008)12 demonstrated that self-esteem contributed significantly with variations in self-perceived scores, however, the amount of variance explained by normative measures of malocclusion is relatively small. The reports of psychosocial impacts are similar to those found in Nigerians in orthodontic treatment, emphasizing the negative consequences of malocclusion26.

Regarding the role of gender in self-perception of malocclusion, Peres et al. (2008) 20 carried out a Poisson regression analysis with robust variance in order to identify the risk factors for dissatisfaction with smile appearance and adjustment of confounding variables such as caries presence and socioeconomic status, had a positive association between malocclusion and smile dissatisfaction only in girls.

Collaborating with this study, Jung et al. (2010)16 observed that crowded anterior teeth cause low self-esteem in adolescent girls and after correction with fixed orthodontic treatment, this improvement significantly, presenting levels similar to adolescents with normal occlusion. In boys, orthodontic treatment does not affect significant differences in self-esteem. Spaljet et al. (2010)22 also detected that female and younger adolescents scored higher in the need for self-perceived orthodontic treatment. However, Momeni and Salehi (2010)17, Nagarajan and Pushpanjali (2010)26 and Peres et al. (2010)10 found a significant correlation between normative and self-perceived malocclusion in both sexes. Already Ajayi (2011)27 obtained greater number of dissatisfaction with tooth appearance and greater desire for orthodontic treatment among boys (P <0.05). This result differs from the others, but since its sample was only 91 students, this probably portrays a local characteristic that should not be generalized to the population.

Regarding the types of malocclusion and the self-perception of adolescents, crowding of the anterior and superior teeth was the occlusal characteristic that most influenced adolescents to seek orthodontic treatment26. The results of the logistic regression analyzes of Marques et al. (2009)4 and de Moura et al. (2013)18 with Brazilian adolescents, indicated that the factor directly involved in the desire for orthodontic treatment and smile dissatisfaction is the misalignment of more than 2mm in the upper incisors, followed by the space between the incisors and anterior open bite of more than 2mm. The study by Tessarollo and collaborators23 (2012) also found that maxillary (P = 0.010) and mandibular misalignment (P = 0.008) are the main reasons for dissatisfaction with appearance, but tooth loss was another characteristic with strong impact = 0.010). Adolescents who scored high on the need for normative orthodontic treatment, had high self-perception, were dissatisfied with the appearance of their teeth and did not smile13.

Considering the degree of malocclusion severity and the level of smile dissatisfaction, Tessarollo et al. (2012)23 and Nagarajan and Pushpanjali (2010)25 found that dissatisfaction with the appearance of teeth increases with increasing malocclusion severity, however, the same does not occur with speech and chewing function. With each increase of normative unit of measure of malocclusion, according to the Dental Aesthetic Index (DAI), there was a 5% increase in the probability of dissatisfaction with the dental appearance.

Paula et al (2011)19 found that dissatisfaction with appearance, higher levels of malocclusion and gingival smile were associated with greater psychosocial impacts, with satisfaction with appearance being the most significant regression coefficient (P <0.001). Similar results were found by Onyeaso et al.26 (2005) who obtained highly significant psychosomatic implications due to malocclusion among subjects with normal or mild malocclusion and those with severe malocclusion (P <0.001), indicating awareness of the malocclusion, dissatisfaction with the appearance of the teeth and the impact of the unfavorable appearance of the teeth compared to those of their peers. Phillips and Beal (2009)21 stated that the level of satisfaction (positive feelings) is more strongly related to self-perception than to the severity of the malocclusion.

Taking into account the prevalence of malocclusions and the great demand for orthodontic treatment in public services, the evaluation of adolescents' self-perception becomes an important tool that can support the planning of this service. Making possible the selection of the most needy patients and the creation of public policies taking into account the principle of equity30, where the less favored psychologically, who have a greater need of support and encouragement are favored in comparison with their counterparts who have a higher self-esteem.


Regarding the self-perception of malocclusions by adolescents, we can conclude that the more severe the malocclusion, the greater the self-perception. However, individuals with low self-esteem tend to perceive imperfections more even in cases of mild malocclusion. Most of the studies observed a positive association between dissatisfaction with the appearance of female teeth and adolescents. The crowding of the anterior region of the maxilla and the space between the teeth were the characteristics of the malocclusion most subjectively perceived.

The literature has shown that adolescents' self-perception of malocclusion has an impact on quality of life, self-esteem and personal satisfaction, and therefore it would be important to include this subjective criterion in orthodontic evaluations so that the most needy individuals can be prioritized, considering the adolescent as a biopsychosocial being.


To the Coordination of Improvement of Higher Level Personnel - CAPES. Authors Aline Cavalcanti da Costa and Fabrícia Soares Rodrigues received financial support from the Coordination for the Improvement of Higher Education Personnel (CAPES) in a scholarship and research format.


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