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Evaluation of the Impact of Orthodontic
Treatment on Patients' Self-Esteem: A Systematic
Review
Rashad I. Shaadouh , Mohammad Y. Hajeer , Ahmad S. Burhan , Mowaffak A. Ajaj , Samer T. Jaber ,
Ahmad Salim Zakaria , Khaldoun M.A. Darwich , Ossama Aljabban , Youssef Latifeh
1. Department of Orthodontics, Faculty of Dentistry, University of Damascus, Damascus, SYR 2. Department of
Orthodontics, Faculty of Dentistry, Al-Watanyia Private University, Hama, SYR 3. Department of Orthodontics, School
of Dental Sciences, Universiti Sains Malaysia, Kelantan, MYS 4. Department of Oral and Maxillofacial Surgery, Faculty
of Dentistry, University of Damascus, Damascus, SYR 5. Department of Endodontics and Restorative Dentistry, Faculty
of Dentistry, University of Damascus, Damascus, SYR 6. Department of Internal Medicine, Faculty of Medicine,
University of Damascus, Damascus, SYR
Corresponding author: Mohammad Y. Hajeer, myhajeer@gmail.com
Abstract
Malocclusion may affect interpersonal relationships, self-esteem (SE), and psychological well-being,
weakening patients' psychological and social activities. Several studies investigated the effect of orthodontic
treatment on these social and psychological aspects, such as SE. However, the direct relationship between SE
and orthodontic treatment has not yet been confirmed. This systematic review aimed to evaluate the
existing evidence in the literature concerning the influences of orthodontic treatment on patients’ SE
systematically and critically. An electronic search in the following databases was done in September 2022:
PubMed®, Web of Science™, Scopus®, Embase®, GoogleTM Scholar, Cochrane Library databases, Trip, and
OpenGrey. Then, the reference list of each candidate study was checked for any potentially linked papers
that the electronic search might not have turned up. Inclusion criteria were set according to the
population/intervention/comparison/outcome/study design (PICOS) framework. For the data collection and
analysis, two reviewers extracted data separately. The risk of bias 2 (RoB-2) and the risk of bias in non-
randomized studies (ROBINS-I) tools were used to assess the risk of bias for randomized controlled trials
(RCTs) and non-RCTs, respectively. The grading of recommendations assessment, development and
evaluation (GRADE) approach was employed to evaluate the quality of the evidence for each finding. Sixteen
studies (five RCTs, seven cohorts, and four cross-sectional) were included in this review. Unfortunately, the
results could not be pooled into a meta-analysis. Only six studies have reported an increase in SE after
orthodontic treatment (P<0.05 in these studies). No agreement between the included studies was observed
regarding the influence of fixed orthodontic treatment, gender, or age on SE. The quality of evidence
supporting these findings ranged from very low to low. There is low evidence indicating that fixed
orthodontic treatment can improve patients' SE. In addition, unclear data are available about the influence
of patients' gender and age on SE after orthodontic treatment. Therefore, high-quality RCTs are required to
develop stronger evidence about this issue.
Categories: Psychology, Dentistry, Oral Medicine
Keywords: fixed orthodontic treatment, orthodontic treatment, self-concept, adults, adolescent, fixed treatment,
orthodontic, psychological, self-esteem
Introduction And Background
Malocclusion is a common public health problem, which causes physical and psychological implications for
patients and influences their daily life [1]. Many studies have shown its negative impact on social
perceptions [2]. It may affect appearance, interpersonal relationships, self-esteem, and psychological health,
weakening patients' psychological and social activities, such as smiling, emotion, and social contact [3,4].
On the other hand, the orthodontic treatment itself and its appliance may affect the psychological and social
activities of patients due to the appearance of these devices [5,6], their effect on speech [7-9], the
accompanying pain and discomfort [10-12], and the associated functional impairment [11].
Due to the growing appreciation of the impact of dentofacial problems on social and psychological health
[13], orthodontists have argued that the aesthetically pleasing appearance of teeth and associated soft tissue
leads to greater self-esteem (SE) and social health [14,15]. As a result, several studies investigated the social
and psychological aspects of malocclusion and orthodontic treatment, such as oral health-related quality of
life (OHRQoL) [1,5] and SE [13,16,17] to understand the impact of malocclusion on patients’ lives and to
develop effective orthodontic care that improves patient’s attitudes toward treatment and their self-concept
and SE [18].
Generally, the self-concept embodies the answer to the question, "Who am I?" [19]. Piers determined self-
1 1 1 1 2
3 4 5 6
Open Access Review
Article DOI: 10.7759/cureus.48064
How to cite this article
Shaadouh R, Hajeer M, Burhan A, et al. (October 31, 2023) Evaluation of the Impact of Orthodontic Treatment on Patients' Self-Esteem: A
Systematic Review. Cureus 15(10): e48064. DOI 10.7759/cureus.48064
concept as a set of attitudes people have about themselves that describe and evaluate their behavior [20].
Moreover, self-concept was defined by Beane et al. as the perceptions that a person has of oneself in relation
to individual attributes and the various roles performed by the person [21]. Self-concept cannot be described
as positive or negative since it is irrelevant to value judgments and represents only a description of the
perceived self. In contrast, SE refers to the estimation that a person makes about the description of one's
self-concept and, more precisely, to what extent one is satisfied or dissatisfied with his/her self-concept, in
whole or in part. Thus, King argued that SE and self-concept represent two discrete dimensions [22].
Self-esteem was defined as a multifaceted notion, for which Harter developed a tool to measure both global
and specific self-worth [23]. Explicit SE refers to beliefs and values in particular domains, such as school
competence or close friendship, whereas global SE refers to one's perception and assessment of oneself as a
person [24]. It has been stated that adolescents with little SE have a higher chance of developing worse
mental and physical health, poorer economic well-being, and higher levels of criminal behavior in adulthood
[25].
Although this well-known and accepted correlation between SE and malocclusion, the direct relationship
between SE and orthodontic treatment has not been confirmed yet; while several studies show that
orthodontic treatment may improve SE scores at the end of treatment [13,17,26], others have found no
differences in SE after the completion of orthodontic treatment [24,27,28]. Thus, there is no clear evidence
about the effect of orthodontic treatment on self-esteem. Additionally, no previous systematic review was
performed on this topic. Therefore, this systematic review aimed to evaluate the existing evidence in the
literature concerning the influences of orthodontic treatment on patients' SE systematically and critically.
The focused review question was "How does orthodontic treatment affect patients’ self-esteem?"
Review
Materials and methods
Scoping Search
A scoping search was conducted in the PubMed database before designing the final systematic review
protocol to verify the existence of any systematic reviews with comparable objectives and to investigate
potentially relevant papers. No literature reviews regarding how orthodontic treatment affects patients' SE
were found as a result of this search. Several articles that were related to the topic of this review were found.
Eligibility Criteria
The participants/interventions/comparisons/outcomes/study design (PICOS) framework was used to define
the inclusion criteria.
Participants: Healthy patients of all ages and malocclusions, both males and females, of all racial groups
undergoing orthodontic treatment were included.
Interventions: Any orthodontic treatment using fixed or removable orthodontic appliances.
Comparisons: In the case of two- or three-arm comparable studies, the comparison group may be any group
of patients who did not undergo any form of orthodontic treatment or a group of patients being treated with
another orthodontic technique different from that in the interventional group or a group of subjects with
normal occlusion.
Outcomes: Patients’ SE after orthodontic treatment is measured by the Rosenberg scale, Harter’s self-
perception profile, the global negative self-evaluation, or any other validated scale for SE assessment. The
effect of the type of orthodontic treatment and patients’ age and gender on SE is determined.
Study design: In English, randomized controlled trials (RCTs) or non-RTC (CCTs), prospective cohort
studies, and cross-sectional studies were included without time of publication restrictions.
Sources and Search Strategy
PubMed®, Web of Science™, Scopus®, Embase®, Google TM Scholar, Cochrane Library, PsychINFO, Trip,
and OpenGrey databases were electronically searched in September 2022 without time limits. The details of
the electronic search strategy for each database are presented in Appendix 1. The keywords used in the
search strategy are listed in Appendix 2. The reference list of each candidate study was checked for any
potentially linked papers that the electronic search might not have turned up.
Study Selection
After electronically removing the duplicated papers retrieved from the databases and manual searches using
2023 Shaadouh et al. Cureus 15(10): e48064. DOI 10.7759/cureus.48064 2 of 20
the Endnote™ reference management software program (Clarivate Analytics, Philadephia, PA, USA), the
titles and abstracts of articles were assessed. Two reviewers (RIS and MYH) independently evaluated the
suitability of each article in light of the selection criteria. Then, the entire text of all articles that potentially
meet the inclusion criteria was assessed by the same two reviewers or could not reach a clear judgment based
on the title or summary. Articles were excluded if they failed to satisfy one or more qualifying criteria. In
case of disagreement and a conversation did not result in agreement, a third reviewer (ASB) was consulted.
Data Collection Process
The following data were among the information extracted from the included articles in this review and
organized into summary tables: author's name, year of publication, country, study design, comparison,
sample size (male/female), mean age, malocclusion, type of orthodontic treatment, questionnaire employed,
questionnaire administration time, main finding, and p-value.
Risk of Bias Assessment of the Studies
First, the risk of bias of each included study was assessed by the two reviewers (RIS and MYH) separately
using Cochrane's risk of bias tool for randomized trials (RoB2) [29] and ROBINS-I tool for non-RCTs [30].
Second, the judgments of both reviewers were compared. In case of disagreement, and a conversation did
not result in agreement, a third reviewer (MAA) was consulted to help reach a decision. For RCTs, the five
domains of the RoB2 tool were judged as having a high, low, or unclear risk of bias.
After that, the overall risk of bias for each study was determined according to the following criteria: a low
risk of bias if all fields were assessed as having a low risk of bias; a moderate risk if one or more fields were
evaluated as having an unclear risk of bias; and a high risk of bias, if one or more fields were assessed as
being at high risk of bias.
For the non-RCTs, the seven domains of the ROBINS-I tool were rated as having a low, moderate, critical, no
information, or serious risk of bias. After that, the overall risk of bias for each study was determined
according to the following criteria: low risk of bias if all fields were assessed as having a low risk of bias; a
moderate risk if all fields were assessed as having a low or moderate risk of bias; serious risk of bias if one or
more fields were assessed as having a serious risk of bias, but no critical risk of bias in any field; critical risk
of bias if one or more fields were assessed as having a critical risk of bias; and no information when there
was a lack of information in one or more key bias categories and no overt indication that the study is at
serious or critical risk of bias.
The Quality of the Evidence
Based on the grading of recommendations assessment, development and evaluation (GRADE) approach, the
strength of the evidence was rated as high, moderate, low, or very low for each outcome. The quality of the
evidence of each outcome was assessed by the two reviewers (RIS and MYH) separately. After that, the
judgments of both reviewers were compared. In case of disagreement and a conversation was not resolved, a
third reviewer (MAA) was consulted to help reach a decision.
Synthesis of Results
Due to the qualitative nature of the data, meta-analysis was not feasible. Instead, a thematic synthesis
approach was employed to synthesize the data. Thematic analysis is a suitable method for qualitative
research [26]. The findings were summarized based on significant and prominent themes. Consequently, the
following thematic headings were identified: (1) effect of orthodontic treatment on SE; (2) the effect of type
of orthodontic treatment on SE; and (3) the effect of age and gender on SE.
Results
Literature Search Flow and the Retrieved Studies
The electronic search in the databases and reference lists yielded 2,768 references. After removing duplicate
references, 597 citations were carefully checked. A total of 575 documents were removed based on checking
the titles and abstracts, and then the eligibility of 22 full-text records was evaluated. As a result, 16 studies
were included in the systematic review [13,17,24,26-28,31-40], and six were excluded. The reasons for
exclusion are given in Appendix 3. Figure 1 shows the PRISMA flow chart for the processes of selection and
inclusion.
2023 Shaadouh et al. Cureus 15(10): e48064. DOI 10.7759/cureus.48064 3 of 20
FIGURE 1: PRISMA 2009 flow diagram of the included studies
Studies’ Characteristics
Table 1 summarizes the characteristics of the included studies. Out of these trials, five were RCTs
[26,27,37,38,40], seven studies were cohort studies [13,24,28,32,34,35,39], and the other four studies had a
cross-sectional design [17,31,33,36]. All of them were in English. These studies were carried out across seven
countries, including the UK [13,34,35,37,38,40], Brazil [26,33], Korea [17,28], the USA [27,31], Spain [36,39],
Belgium [24], Norway [32].
Study
setting
Methods Participants Interventions Results
Author,
Year,Country Studydesign Type of comparison Patients (female/male) and
age range (years) Malocclusion Type of orthodontic
treatment Malocclusion
assessmentUsedquestionnaireQuestionnaire
administration
time Main findingsP-valve
Pithon et al.
2021 [26],
Brazil RCT Treated group vs Control
group 44 adult patients (31
female/13 male), age: 17-
49, TG: 22 patients, CG: 22
patients Skeletal class I and
Angle Class I or II
malocclusions with
missing lateral incisors Fixed appliances NR Rosenberg’s
Self-Esteem
Scale(RSES) TG: T1:
before
orthodontic
treatment, T2:
afterorthodontic
treatment,
CG: T1: at
baseline, T2:
after 12
The spacing
resulting from
missing
maxillary
lateral incisors
had anegative
impact on the
self-esteem of
theparticipants,
whileorthodontically<0.001
2023 Shaadouh et al. Cureus 15(10): e48064. DOI 10.7759/cureus.48064 4 of 20
months closing those
spaces had a
positive
impact on this
aspect
Avontroodt
et al. 2019
[24],Belgium Cohort Pre-treatment vs Post-
treatment T0: 326 adolescents (172
girls/154 boys), age: 11-16
years, T2: 123 adolescentsNR Fixed appliances IOTN Harter’s Self-
Perception
Profile for
Adolescents
(SPPA) T0: baseline,
T1: namely 1
year after the
start of
treatment
(T1), T2:1
month after
the end of
treatment
There was no
statistically
significant
difference in
allquestionnaire
scores
between T0
and T2 Global
self-esteem
acts as a
stable
construct
during
orthodontic
treatment 0.0564
Choi et al.
2017 [28],
Korea Cohort Pre-treatment vs Post-
treatment T0: 66 adult patients (36
female/30 male), age: 19-39
years, mean age: 24.2 ± 5.2
years, T2: 66 adult patientsClass I, II, or III with or
without premolar
extraction Fixed appliances IOTN Rosenberg
Self-esteem
Scale(RSES) T0: atbaseline, T1:
12 months
aftertreatment
initiation, T2:
debonding There was no
statistically
significant
difference in
allquestionnaire
scores
between T0
and T2 > 0.05
de Couto
Nascimento
et al. 2016
[33], BrazilProspective
cross-
sectional
design Pre-treatment vs Post-
treatment T1: 102 adult patients (77
female/25 male), age: 18-66
years, T2: 102 adult patientsMalocclusion s caused by
dental losses and
agenesis Fixed appliances NR Rosenberg’s
Self-Esteem
Scale(RSE)T1: early
orthodontic
treatment (1–
3 months of
treatment),
T2: after
leveling and
alignment
phase
(minimum of
8 months of
treatment)
Orthodontic
treatment
causes a
significant
increase in
patients’ self-
esteem and
QoL <0.001
Mandall et
al. 2016
[40], UK RCT Treated group vs Control
group T1:73 patients (39 female/34
male), TG: 35 patients, CG:
38 patients (mean age: 9±
0.8 years), T2: 65 patients
(33 female/32 male), TG: 33
patients (mean age: 15
years ± 10.3 months), CG:
32 patients (mean age: 15.3
years ± 10.1 months) Class III malocclusion FM NR Piers Harris
questionnaireT1: atbaseline, T2:
at 6-year
follow-up Earlyprotraction
facemask
treatment
does not
seem to
confer a
clinically
significant
psychosocial
benefit 0.48
Romero-
Maroto et
al. 2015
[36], SpainCross-
sectional Treated group vs Control
group 170 adult patients (100
female/70 male), mean age:
29.80 ± 9.55 years, TG: 85
patients, CG: 85 patients Class I, Class II, and
Class III malocclusion
with anterior
malalignment and no
need for extractions,
dental crowding >6 mm Fixed appliances NR Rosenberg’s
Self-Esteem
Scale(RSES) T1: b efore
treatment, T2:
after 3-6
months of
treatment No significant
differences
were found in
relation to
self-esteem
between the
groups 0.839
T0: baseline,
T1: after 1 Undergoing
fixed
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Johal et al.
2014 [13],
United
Kingdom Cohort Pre-treatment vs Post-
treatment T0: 61 adult patients (48
female /13 male), age: 18-
71 years, mean age: 41.2,
T4: 60 adult patients NR Fixed appliances IOTN Rosenberg’s
Self-Esteem
Scale (RSE)month, T2:
after 3
months, T3:
after 6
months, T4:
post-treatment orthodontic
therapy
appeared to
have a
significant
improvement
in self-esteem.0.002
Seehra et
al. 2013
[35], UK Cohort Pre-treatment vs Post-
treatment T0: 27 patients (14
female/13 male), mean age:
14.6 (±1.5) years, T1: 27
patients Classes I, II, or III FixApp/FuncApp/RetainersIOTN Harter’s Self-
Perception
Profile T0: Pre-
treatment, T1:
post-treatment There were no
significant
differences in
the pre-and
posttreatment
scores of the
participants
on the Harter
measure of
self-esteem
scale NR
Mandall et
al. 2012
[38], UK RCT Treated group vs Control
group T1:73 patients (39 female/34
male), TG: 35 patients
(mean age: 8.7±0.9 years),
CG: 38 patients (mean age:
9±0.8 years), T3: 63 patients
(33 female/30 male), TG: 30
patients (mean age:
12.1±0.9 years), CG: 33
patients (mean age:
12.3±0.8 years) Class III malocclusion FM NR Piers Harris
questionnaireT1: atbaseline, T2:
at 15-month
follow-up, T3:
at 3-year
follow-up There were
tiny changes
in self-esteem
over time and
no statistically
significant
increase in
self-esteem as
a result of
protraction
facemask
treatment 0.56
Jung et al.
2010 [17],
Korea Cross-
sectional DB: after debonding of fixed
appliances) group FO: FOA
treatment group RO: During or
finished ROA treatment group
NO: No orthodontic treatment
group 4,509 patients (2,944
female/1,565 male), age: 12-
15 years Crowding/protrusion/other
types of malocclusion FixApp/RemoApp NR Rosenberg’s
Self-Esteem
Scale (RSE)1 week before
the clinical
examinations
Anterior
crowding
causes low
self-esteem in
adolescent
girls. FO or
RO treatment
could not
improve self-
esteem during
treatment;
however, after
fixedtreatment,
significantly
higher self-
esteem was
observed in
the girls
NR
Mandall et
al. 2010
[37], UK RCT Treated group vs Control
group T1:73 patients (39 female/34
male), TG: 35 patients
(mean age: 8.7±0.9 years),
CG: 38 patients (mean age:
9±0.8 years), T2: 69
patients, TG: 33 patients
(mean age: 10±0.9 years),
CG: 36 patients (mean age:
10.3±0.8 years) Class III malocclusion FM NR Piers Harris
questionnaireT1: atbaseline, T2:
at 15-month
follow-up There was no
increased self-
esteem
(Piers–Harris
score) for
treated
children
compared with
controls 0.22
there appears
to be a
significant
effect of
orthodontic
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Show et al.
2007 [34],
UK Cohort Group 1: Prior need for
treatment in 1981 –treatment
received by 2001. Group 2:
Prior need for treatment in
1981 – no treatment by 2001
Group 3: No prior need for
treatment in 1981 – no
treatment by 2001 Group 4:
No prior need for treatment in
1981 – treatment received by
2001 T0: 1,018 patients, Age: 11-
12 years, T1: 332 (188
female/144 male), age:
29.6-32.4 years NR NR ICON Rosenberg
Self-Esteem
Scale (RSE)T0: atbaseline
(1981) T1:
third follow up
(2001)
treatment on
self-esteem in
later life. The
group of
participants
who had a
prior need in
1981, but who
did not receive
treatment, had
lower self-
esteem in
2001 than the
control group
(no prior need,
no treatment)
andsignificantly
lower self-
esteem than
the prior need
group who
received
treatment; this
last group had
the highest
mean self-
esteem in
2001
< 0.01
Birkeland et
al. 2000
[32],Norway Cohort ROA group vs FOA group vs
Control group T1: 359 children, mean age:
11 years, T2: 224 children
(120 girls/104 boys), mean
age: 15 years RemoApp, G:
16 patients/FixApp, G: 51
patients, CG: 157 patients NR FixApp/RemoApp IONT PAR The Global
Negative
Self-Evaluation
Scale (GSE)T1: atbaseline (age:
11 years old),
T2: 15 years
old An overall
improvement
in GES score
over the 4-
year period
was found. A
gender
difference was
found <0.001
Varela et al.
1995 [39],
Spain Cohort Pre-treatment vs Post-
treatment T1: 40 adult patients (37
female/3 male), age: 18-42
years, T3: 40 adult patients
(37 female/3 male) moder ate to severe
malocclusions Fixed appliances Threeindependent
orthodontistsTennessee
Self-Concept
Scale (TSCS)T1: before
treatment, T2:
after 6
months of
treatment, T3:
from 1 to 4
weeks after
the end of
activetreatment. Changes
across the
threemeasurement
periods were
not significantNR
Albino et al.
1994 [27],
USA RCT Treated group vs Control
group T1: 93 patients (46
female/47 male), age: 11-
14, TG: 44, CG: 49, T5: 76
patients, TG: 39, CG: 37 Mild-to-moderate
malocclusions Fixed appliances Treatment
Priority
Index Coopersmith
Self-esteem
Inventory
Rosenberg
Self-image
Inventory
T1: before
treatment, T2:
during
treatment (8-
10 months
after began),
T3: on
termination of
activetreatment, T4:
6 months
aftertermination,
T5: 1 year
after treatment did
not affect the
subjects' self-
esteem NR
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termination
O'Regan et
al. 1991
[31], USA Cross-
sectional Pre-treatment group vs Post-
treatment group vs Control
group 220 patients (144 female/76
male), pre-TG: 97 patients,
mean age: 13.3. post-TG:
45 patients, mean age: 15.8,
CG: 78 patients, mean age:
13.1 NR Fixed appliances NR The Piers
and Harris
self-rating
questionnaireNR Improvement
in dental
and/or facial
aesthetics
does not
necessarily
lead to an
increase in
self-esteem NR
TABLE 1: Characteristics of the included studies in the systematic review
RCT: Randomized clinical trials, CSS: cross-sectional, TG: Treated group, CG: control group, FixApp: fixed orthodontic appliances, RemoApp: removable
orthodontic appliances, FuncApp: functional appliances, FM: face mask, IOTN: Index of orthodontic treatment need, PAR: Peer assessment rating, IOCN:
Index of complexity, outcome and need, NR: not reported
From these 16 studies, 6,287 participants were included (3,996 females and 2,291 males). All these studies
included a mixture of both genders, and there was no single-gender study. Six studies evaluated adult
patients between 17 and 71 years [13,26,28,33,36,39]. Children and adolescents aged between 7 and 15 were
evaluated in nine studies [17,24,27,31,32,35,37,38,40]. Noteworthy, the Show et al.'s cohort study followed
patients over 20 years with age at baseline 11-12 years, and the mean age at the final follow-up assessment
was 31.25 years [34].
To assess patients’ SE, the Rosenberg’s Self-Esteem (RSE) questionnaire was used in eight studies [13,17,26-
28,33,34,36], and the Piers and Harris self-rating questionnaire in four studies [31,37,38,40]. In addition,
Harter’s Self-Perception Profile for Adolescents (SPPA) was used in two studies [24,35]. Coopersmith Self-
esteem Inventory, the Global Negative Self-Evaluation Scale (GSE), and Tennessee Self-Concept Scale (TSCS)
were also used by Albino et al. [27], Birkeland et al. [32], and Varela et al. [39], respectively, to assess SE.
Self-esteem was studied with several types of malocclusions among the included studies; patients with mild-
to-moderate malocclusion were assessed by Albino et al. [27]; moderate-to-severe malocclusion by Varela et
al. [39]; Class III malocclusion in children patients was studied in three studies [37,38,40]; and cases with
dental loss or agenesis and missing lateral incisors were evaluated by de Couto Nascimento et al. [33] and
Pithon et al. [26], respectively. Jung's study focused on patients with crowding or protrusion or both of them
[17]. Romero-Maroto et al.'s trial included patients with anterior crowding less than 6 mm with Class I, Class
II, or Class III malocclusion and no need for extractions [36]. On the other hand, patients with Class I, II, or
III with or without premolar extraction were included in Choi et al.'s and Seehra et al.'s studies [28,35]. In
contrast, the other included studies lacked this information about malocclusion type [13,24,31,32,34,35].
The Index of Orthodontic Treatment Need (IOTN) scale defined the treatment need and assessed
malocclusion in five studies [13,24,28,32,35]. Meanwhile, the Index of Complexity, Outcome and Need
(ICON), and Treatment Priority Index were used in two studies by Show et al. and Albino et al., respectively
[27,34]. Three independent orthodontists assessed malocclusion severity in Varela et al.'s trial [39].
Among the included studies, fixed orthodontic appliances were used in patients’ treatment in nine trials
[13,24,26-28,31,33,36,39]; a face mask with a bonded maxillary acrylic expansion device was used in three
trials [37,38,40]; and, in the other two trials, a mixture of fixed or removable orthodontic appliances was
used in different groups [17,32]. In the trial reported by Seehra et al., 59% and 23% of patients were treated
with class II functional appliances, followed by fixed appliances and fixed appliances only, respectively [35].
Out of the 16 included studies in this systematic review, eight compared treated patients vs the control
group (untreated patients) [26,27,32,34,36-38,40]. However, in the other six single group before-after
studies, patients' SE was compared between pre- and post-treatment [13,24,28,33,35,39]. O'Regan et al., in a
cross-sectional study, compared patients’ SE between three groups (pre-treatment group vs post-treatment
group vs control group) [31]. Lastly, the study of Jung divided patients into four groups (DB: after debonding
of fixed appliances group, FO: fixed appliances treatment group, RO: During or finished removable
appliances treatment group, NO: No orthodontic treatment group) and compared patients’ SE between them
[17].
Risk of Bias in the Included Studies
Figures 2-3 display an overview of the included RCTs' overall risk of bias. The five included RCTs were
classified as having some concern of bias [26,27,37,38,40]. Participants’ blinding was the most problematic
field for all these trials. Moreover, the random sequence generation was unclear in Albino et al.'s study,
2023 Shaadouh et al. Cureus 15(10): e48064. DOI 10.7759/cureus.48064 8 of 20
reflecting some concern of bias in the randomization process [27]. More details about the risk of bias
assessment of the included RCTs are given in Appendix 4.
FIGURE 2: Risk of bias graph: The review authors’ judgments about
each item's risk of bias for the included RCTs
Domains:
D1: Bias arising from the randomization process
D2: Bias due to deviations from the intended intervention
D3: Bias due to missing outcome data
D4: Bias in the measurement of the outcome
D5: Bias in the selection of the reported result
Judgment:
Yellow circle: Some concerns
Green circle: Low risk of bias
FIGURE 3: Risk of bias summary: The review authors’ judgments about
each item's risk of bias, presented as percentages across all the
included RCTs
For non-RCTs, all of them were at serious risk of bias [13,17,24,28,31-36,39]. Bias in the measurement of
outcomes was the most problematic field in most of the studies [13,17,24,28,31-34,36,39], due to the
outcome assessors being aware of the intervention received by study participants. Figures 4-5 summarize the
overall risk of bias in the non-RCT-included studies. More details about the risk of bias assessment are given
in Appendix 5.
2023 Shaadouh et al. Cureus 15(10): e48064. DOI 10.7759/cureus.48064 9 of 20
FIGURE 4: Risk of bias graph: The review authors’ judgments about
each item's risk of bias for the included non-RCTs
Domains:
D1: Bias due to confounding
D2: Bias due to selection of participants
D3: Bias in the classification of interventions
D4: Bias due to the deviations from intended interventions
D5: Bias due to missing data
D6: Bias in the measurement of outcomes
D7: Bias in the selection of the reported result
Judgment:
Red circle: Serious risk of bias; Yellow circle: Some concerns; Green circle: Low risk of bias
FIGURE 5: Risk of bias summary: The review authors’ judgments about
each item's risk of bias are presented as percentages across all the
included non-RCTs.
Effects of Interventions: Effect of Orthodontic Treatment on Self-Esteem
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Sixteen studies assessed the influence of orthodontic treatment on patient SE in this systematic review. Only
six studies have reported a significant increase in patient SE scores after orthodontic treatment (P<0.05) in
these studies [13,17,26,32-34]. On the other hand, no statistically significant difference in SE scores
following orthodontic treatment was observed in the other 10 studies [24,27,28,31,35-40]. Low-quality
evidence supported this outcome based on the GRADE approach (Table 2).
Quality assessment criteria Summary of the findings
Comments
No. of studies Risk of
bias InconsistencyIndirectnessImprecisionOtherconsiderationsNo. of
patientsEffects Certainty
Absolute
(95% CI)Relative
(95%CI)
Effect of orthodontic treatment on self-esteem
5 RCT (PGD) 7
cohort studies 4
CSS SeriousSerious serious NotSerious None 6287- -
⨁◯◯◯
a low Six studies showed a significant
increase in self-esteem after treatment
(p
The effect of type of orthodontic treatment on self -esteem: Fixed orthodontic appliances:
2 RCT (PGD) 6
cohort studies 4
CSS Seriousserious serious Serious Serious 1122- -
⨁◯◯◯
b Very
Low Five studies showed a significant
increase in self-esteem after treatment
(p
Facemask and bonded maxillary acrylic expansio n device:
3 RCT (PGD) SeriousNot SeriousNot SeriousNotSerious None 73 - - ⨁⨁⨁◯c
ModerateThere was not a significant difference in
self-esteem between the control and the
experimental group.
Fixed versus removable orthodontic appliances
1 cohort study 1
CSS Seriousserious Serious Serious Serious 4868- -
⨁◯◯◯
d Very
Low Fixed orthodontic treatment had a more
significant effect on self-esteem than the
removable appliances treatment.
The effect of gender on self-esteem:
3 cohort study 2
CSS Seriousserious Serious Serious Serious 5088- -
⨁◯◯◯
e Very
Low
The effect of age on self-esteem:
2 cohort study Seriousserious Serious Serious Serious 496 - -
⨁◯◯◯
f VeryLow
TABLE 2: Summary of the findings table according to the GRADE guidelines for the included
trials
CI: confidence interval, PGD: parallel-group design, CSS: cross-sectional design
a. Decline one level for risk of bias (some concern risk of bias [26,27,37,38,40] and high risk of bias [13,17,24,28,31-36,39]), one for inconsistency*, one
for indirectness***
b. Decline one level for risk of bias (some concern risk of bias [26,27] and high risk of bias [13,17,24,28,31-33,35,36,39]), one for inconsistency*, one for
indirectness***, and one for imprecision **
c. Decline one level for risk of bias (some concern risk of bias [37,38,40])
d. Decline one level for risk of bias (high risk of bias [17,32]), one for inconsistency*, one for indirectness***, and one for imprecision **
e. Decline one level for risk of bias (high risk of bias [17,24,31,32,36]), one for inconsistency*, one for indirectness***, and one for imprecision **
f. Decline one level for risk of bias (high risk of bias [24,36]), one for inconsistency*, one for indirectness***, and one for imprecision **
2023 Shaadouh et al. Cureus 15(10): e48064. DOI 10.7759/cureus.48064 11 of 20
* Wide variance of point estimates across studies
** Limited number of trials
*** Interventions delivered differently in different settings
First: The Effect of Type of Orthodontic Treatment on Self-Esteem
The fixed orthodontic appliances: The effect of fixed orthodontic treatment on patient SE was studied by 12
studies with different types of malocclusion [13,17,24,26-28,31-33,35,36,39]. A significant increase in SE
scores was reported in five studies [13,17,26,32,33]. However, in the other seven studies, no statistically
significant differences were noted in patients’ SE scores [24,27,28,31,35,36,39]. The strength of the evidence
supporting this outcome, according to the GRADE approach, was low.
Facemask and bonded maxillary acrylic expansion device: Treatment with face masks and bonded maxillary
acrylic expansion devices was evaluated by Mandall et al. [37] in three trials and over a long period (six years
of follow-up). Tiny changes in SE over time as a result of protraction facemask treatment have been
reported, and no statistically significant increase in SE score of children patients with class III malocclusion
was found after 15 months, three years, and six years of treatment compared to baseline (P=0.22, P=0.56,
P=0.48, respectively) [38,40]. The strength of the evidence supporting this outcome was moderate, based on
the GRADE approach.
The fixed versus removable orthodontic appliances: Jung [17] and Birkeland et al.'s [32] studies investigated
the impact of fixed and removable orthodontic treatment on SE in adolescent patients aged 11-16. They
found that fixed orthodontic treatment had a more significant effect on SE (P=0.009, P<0.05, respectively)
compared to the removable appliances treatment, as no significant increase in SE score was observed after
treatment with these appliances (P=0.75, P>0.05, respectively). Notably, no information was reported in
these studies about the types of malocclusions, types of removable appliances used, or duration of
treatment. The strength of the evidence supporting this outcome was low, based on the GRADE approach.
Second: The effect of age and gender on SE: The relationship between patients’ sex and SE after orthodontic
treatment was evaluated in five studies [17,24,31,32,36]. Two assessed the effect of both patients’ ages and
gender on SE [24,36]. In regards to patients’ gender, Jung [17] noted that SE index (SI) increased in girls after
fixed appliances treatment (SI=2.71±0.45, 2.86±0.43 in the untreated group, and after the fixed orthodontic
treatment group, respectively, P<0.05). However, for the boys, orthodontic treatment did not affect SE levels
(SI=2.80±0.47, 2.89±0.48 in the untreated group, and after fixed orthodontic treatment group, respectively,
P>0.05) [17]. In contrast, Birkeland et al. [32] found that more girls than boys had developed negative self-
evaluation after orthodontic treatment (P<0.001). Avontroodt et al.'s study on adolescents showed a decrease
in SE levels for females and an increase for males between baseline and after 12 months of treatment [24].
The same results were also reported by O’Regan et al.'s study, as girls had lower SE than boys after
orthodontic treatment [31]. Despite that, different results were reported by Romero-Maroto et al. in adult
patients where no correlation between SE and gender was found [36]. Very low-quality evidence supported
this outcome based on the GRADE approach. Regarding patients’ age, the Avontroodt et al. study showed
that younger children had an improvement or stabilization in self-perception, whereas a decreased self-
perception was found for older children [24]. On the other hand, according to Romero-Maroto et al., age did
not have a significant correlation with SE, and it did not appear to be a relevant variable to consider [36].
Based on the GRADE approach, very low-quality evidence supported this outcome.
Discussion
Sixteen studies were included in this systematic review [13,17,24,26-28,31-40], assessing orthodontic
treatment's impact on SE among many children, adolescents, and adult patients. Unfortunately, the
interventions, the participants, the employed measurement scale, and the types of malocclusions were
widely varied across these studies. Therefore, the results could not be pooled into a meta-analysis.
None of the included trials were judged to be at low risk of bias, and most were at high risk. This has affected
the confidence in these findings, and the level or strength of evidence that can be gleaned from the included
papers was relatively low.
Effect of Orthodontic Treatment on Self-Esteem
No agreement between the included studies was observed regarding the influence of orthodontic treatment
on SE. Only six of the 16 included studies in this review have reported a significant increase in patients’ SE
scores after orthodontic treatment procedures (P<0.05) [13,17,26,32-34]. This may be due to the higher
satisfaction with dental appearance after fixed orthodontic treatment in these studies, which may positively
affect SE. However, the other 10 trials have not observed any statistically significant difference in SE scores
due to treatment [24,27,28,31,35-40]. This disagreement may be attributed to the fact that SE is a very
2023 Shaadouh et al. Cureus 15(10): e48064. DOI 10.7759/cureus.48064 12 of 20
complex topic that can change greatly during life’s stages. Moreover, it is not just impacted by one factor,
such as malocclusion. Thus, there may be a range of interactions with orthodontic therapy.
The Effect of the Type of Orthodontic Treatment on Self-Esteem
The fixed orthodontic appliances: Twelve studies assessed the changes in SE levels due to treatment with
fixed orthodontic appliances. There was uncertainty in the evidence as to whether or not there was an
improvement in SE at the end of the treatment. A statistically significant increase in SE scores was reported
due to treatment in five studies [13,17,26,32,33]. In contrast, in the other studies, no differences were
reported [24,27,28,31,35,36,39]. This inconsistency may be attributed to the differences in the ages,
demographic characteristics, types of malocclusions of the samples, and the absence of controlling for other
confounder factors that could be responsible for part of the discrepancy between these studies.
Quick correct of teeth alignment can usually be achieved with fixed orthodontic treatment [17]; this may
have a positive effect on a patient's SE, as the beautiful and well-aligned smile may boost patients’
confidence and improve their appearance, which can, in turn, improve their SE [41]. On the other hand, the
effect of malocclusion on SE differs between people, depending on the personal perspective of the individual
and his satisfaction with dental appearance, as some people consider dental appearance an important factor
in their self-evaluation, while others see that dental appearance is not important and does not affect their
self-evaluation [42].
Facemask and bonded maxillary acrylic expansion device: No significant increase in SE scores as a result of
treatment with a face mask and a bonded maxillary acrylic expansion device in children with class III
malocclusion was found by Mandall et al. over six years of follow-up [37,38,40]. This may be because of that
the effect of orthopedic treatment alone was not strong enough to influence Piers-Harris scores, as it does
not have an impact on teeth appearance [37]. It is also noteworthy that the questionnaire used in these
studies does not include items specifically related to the face or teeth, and it is not designed to assess SE in
these specific areas [20].
The fixed versus removable orthodontic appliances: As expected, removable orthodontic appliances had less
effect on SE than fixed orthodontic appliances, according to Jung [17] and Birkeland et al. [32]. Usually,
malocclusion cannot be completely corrected by removable appliance treatment [17]. Thus, psychological
improvement might not be observed if some malocclusion still existed.
The Effect of Gender and Age on Self-Esteem
A few studies evaluated the effect of patients’ gender on SE after orthodontic treatment [17,24,31,32,36]. All
of these studies were conducted on adolescent patients between 11 and 16 years of age, except for the study
of Romero-Maroto et al., which included adult patients with a mean age of 29.80±9.55 years [36]. The results
of this factor were different and somehow opposed between these studies. Therefore, the relationship
between SE and patients’ gender cannot be emphasized in this review due to this disagreement. Both males
and females who feel physically attractive tend to have higher SE [43]; however, many studies have shown
that, during adolescence, girls’ attitudes about their appearance become more negative [44]. This difference
between girls and boys may be because females are usually more conscious of their body image as the
standards of aesthetics and beauty are more clearly defined for them [45]. This decline in girls’ perceived
physical attractiveness is supposed to affect SE negatively [46]. This may also be reflected in orthodontic
treatment, as females were reported to have greater concerns at the start and higher expectations at the end
of treatment than males [47]. This may explain the results of Avontroodt et al., Birkeland et al., and O’Regan
et al. studies, as females, had lower SE after orthodontic treatment than males [24,31,32].
There was insufficient evidence about the relationship between patients’ age and SE score after orthodontic
treatment. Only two cohort trials evaluated this variable after fixed orthodontic treatment [24,36] and
reported conflicting results. According to Avontroodt et al.'s study on adolescents, an inverse relationship
may exist between patients’ age at the start of treatment and SE after treatment in studied subjects. This
result disagrees with previous reviews about the development of SE over age in normal persons that have
found an increase in SE from adolescence to middle adulthood [48]. Therefore, these results may suggest
that early initiation of orthodontic treatment positively impacts SE more than in 14-year-old adolescents
[24]. Romero-Maroto et al.'s study on adult patients reported that age had no significant correlation with SE.
This difference with the previous study of Avontroodt et al. could be explained by the difference in the
patients' ages (adolescents versus adults, respectively) between these studies.
Limitations of the current review
One main limitation of this review is that only a small number of RCTs were included; all of them, including
non-RCTs, were at moderate-to-serious risk of bias. This has affected the degree of confidence in the
findings obtained. Another limitation of this systematic review was the variations between the included
studies regarding the type of malocclusion, method of SE assessment, and assessment times. Hence, the
results could not be pooled into a meta-analysis to provide an accurate estimate of the treatment effect. In
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addition, the effect of gender and age on patients' SE could not be confirmed across the included studies, and
more studies are needed to establish good evidence in this field.
Conclusions
There is low-quality evidence indicating that orthodontic treatment can improve patients’ self-esteem at the
end of treatment. Results are conflicting about the effect of orthodontic treatment with fixed appliances on
self-esteem. However, treatment with these appliances has a greater effect on self-esteem than that with
removable appliances. Low-quality evidence supports these results. The influence of patients’ gender or age
on self-esteem after orthodontic treatment is not clear. Further well-conducted studies using validated
measurement scales of self-esteem are required to arrive at more robust conclusions with attention paid to
the gender and age effect and the need for long-term follow-up periods.
Appendices
Database Search Strategy
CENTRAL
(TheCochrane
Library)#1 malocclusion OR Class I OR Class II OR Class III OR overjet OR overbite OR crowding OR spaces OR protrusion OR
retrognathism OR malalignment OR orthodontic* OR Orthodontic treatment OR Orthodontic therapy OR fixed appliances OR
removable appliances OR myofunctional appliances OR children OR adolescence OR adults #2 Self OR Self-esteem OR SE
OR self-perception OR Rosenberg’s self-esteem scale OR RSE OR Harter’s self-perception profile OR SPPC OR the Global
Negative Self-evaluation OR the Self-esteem inventory OR SEI #3 #1 AND #2
EMBASE#1 malocclusion OR Class I OR Class II OR Class III OR overjet OR overbite OR crowding OR spaces OR protrusion OR
retrognathism OR malalignment OR orthodontic* OR Orthodontic treatment OR Orthodontic therapy OR fixed appliances OR
removable appliances OR myofunctional appliances OR children OR adolescence OR adults #2 Self OR Self-esteem OR SE
OR self-perception OR Rosenberg’s self-esteem scale OR RSE OR Harter’s self-perception profile OR SPPC OR the Global
Negative Self-evaluation OR the Self-esteem inventory OR SEI #3 #1 AND #2
PubMed#1 malocclusion OR Class I OR Class II OR Class III OR overjet OR overbite OR crowding OR spaces OR protrusion OR
retrognathism OR malalignment OR orthodontic* OR Orthodontic treatment OR Orthodontic therapy OR fixed appliances OR
removable appliances OR myofunctional appliances OR children OR adolescence OR adults #2 Self OR Self-esteem OR SE
OR self-perception OR Rosenberg’s self-esteem scale OR RSE OR Harter’s self-perception profile OR SPPC OR the Global
Negative Self-evaluation OR the Self-esteem inventory OR SEI #3 #1 AND #2
Google
Scholar#1 (malocclusion OR Class I OR Class II OR Class III OR overjet OR overbite OR crowding OR spaces OR protrusion OR
retrognathism OR malalignment OR orthodontic* OR Orthodontic treatment OR Orthodontic therapy OR fixed appliances OR
removable appliances OR myofunctional appliances OR children OR adolescence OR adults) AND (Self OR Self-esteem OR
SE OR self-perception OR Rosenberg’s self-esteem scale OR RSE OR Harter’s self-perception profile OR SPPC OR the
Global Negative Self-evaluation OR the Self-esteem inventory OR SEI)
Scopus#1 TITLE-ABS-KEY (malocclusion OR Class I OR Class II OR Class III OR overjet OR overbite OR crowding OR spaces OR
protrusion OR retrognathism OR malalignment OR orthodontic* OR Orthodontic treatment OR Orthodontic therapy OR fixed
appliances OR removable appliances OR myofunctional appliances OR children OR adolescence OR adults). #2 TITLE-ABS-
KEY (Self OR Self-esteem OR SE OR self-perception OR Rosenberg’s self-esteem scale OR RSE OR Harter’s self-perception
profile OR SPPC OR the Global Negative Self-evaluation OR the Self-esteem inventory OR SEI) #3 #1 AND #2
Web of
Science#1TS= (malocclusion OR Class I OR Class II OR Class III OR overjet OR overbite OR crowding OR spaces OR protrusion OR
retrognathism OR malalignment OR orthodontic* OR Orthodontic treatment OR Orthodontic therapy OR fixed appliances OR
removable appliances OR myofunctional appliances OR children OR adolescence OR adults). #2TS= (Self OR Self-esteem
OR SE OR self-perception OR Rosenberg’s self-esteem scale OR RSE OR Harter’s self-perception profile OR SPPC OR the
Global Negative Self-evaluation OR the Self-esteem inventory OR SEI). #3TS= #1 AND #2
Trip (malocclusion OR Class I OR Class II OR Class III OR overjet OR overbite OR crowding OR spaces OR protrusion OR
retrognathism OR malalignment OR orthodontic* OR Orthodontic treatment OR Orthodontic therapy OR fixed appliances OR
removable appliances OR myofunctional appliances OR children OR adolescence OR adults) AND (Self OR Self-esteem OR
SE OR self-perception OR Rosenberg’s self-esteem scale OR RSE OR Harter’s self-perception profile OR SPPC OR the
Global Negative Self-evaluation OR the Self-esteem inventory OR SEI)
OpenGrey#1 orthodontic AND self-esteem #2 Self OR Self-esteem OR SE OR self-perception OR Rosenberg’s self-esteem scale OR
RSE OR Harter’s self-perception profile OR SPPC OR the Global Negative Self-evaluation OR the Self-esteem inventory OR
SEI
TABLE 3: Appendix 1: Electronic search strategy used in the current review
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Orthodontic Malocclusion Self-esteem
Orthodontic treatment Class I self-perception
Orthodontic therapy Class II self
Fixed appliances Class III Rosenberg’s self-esteem scale
Removable appliances overjet Harter’s self-perception profile
Myofunctional appliances overbite the Global Negative Self-evaluation
Crowding Self-esteem inventory
Spaces Piers Harris questionnaire
malalignment
Protrusion
Retrognathism
TABLE 4: Appendix 2: Keywords used in the search
Authors Title Reasons
Vulugundam
et al. 2021Is orthodontic treatment associated with
changes in self-esteem during
adolescence? A longitudinal study Retrospective study
Majid et al.
2021 A comparison of self-esteem between
patients undergoing fixed orthodontic
treatment to those not receiving
orthodontic treatment This study did not meet the inclusion criteria for comparison: Group A: patients
currently receiving no orthodontic treatment or the start of the treatment was
less than six months. Group B: patients receiving orthodontic treatment in the
past six months or more
Arrow et al.
2011 Quality of life and psychosocial outcomes
after fixed orthodontic treatment: a 17-
year observational cohort study Retrospective study
Gazit-
Rappaport
et al. 2010Psychosocial reward of orthodontic
treatment in adult patients Self-esteem was not evaluated
Vaida et al.
2009 Correlations between the changes in
patients’ dentofacial morphology at the
end of the orthodontic treatment and the
psychological variables Self-esteem was not assessed pre-treatment, and there is no comparison with
a control group
Kenealy et
al. 2007 The Cardiff dental study: A 20-year critical
evaluation of the psychological health gain
from orthodontic treatment This study was the same as another article included in the review (A 20-year
cohort study of health gain from orthodontic treatment: Psychological
outcome), the same research team
TABLE 5: Appendix 3: Excluded articles with reasons
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Study Randomization process
Deviations
from intended
interventions
Missing
outcome data
Measurement of the
outcome
Selection of the
reported result
Over-all
bias
Albino
et al.1994[27] Some concerns: No mention
of the method used for
randomisation “patients were
randomly assigned to one of
the study groups”(Page 84).Someconcerns:
Blinding of
participants and
people
delivering the
intervention
cannot be
performed. Low risk: No
dropouts were
reported. Low risk: No details of
blinding of outcome
assessors. But we
judge that the outcome
was not likely to be
influenced by
knowledge of the
intervention receivedLow risk: The
protocol was not
registered. But the
pre-defined
outcomes mentioned
in the methods
section seemed to
have been reported.Someconcerns
Mandall
et al.2010[37] Low risk: The randomization
list was generated in
randomization blocks of 10
with stratification according
to gender. The computer-
generated randomization
sequence was concealed
centrally Someconcerns:
Blinding of
participants and
people
delivering the
intervention
cannot be
performed. Low risk: 4
participants were
excluded.
missing outcome
data occurred for
reasons that are
unrelated to the
outcome Low risk: The
investigators performing
the measurements and
data analysis were
blinded from the group
assignments Low risk: The
protocol was not
registered. However,
the pre-defined
outcomes mentioned
in the methods
section seemed
reported. Someconcerns
Mandall
et al.2012[38] Low risk: The randomization
list was generated in
randomization blocks of 10
with stratification according
to gender. The computer-
generated randomization
sequence was concealed
centrally Someconcerns:
Blinding of
participants and
people
delivering the
intervention
cannot be
performed. Low risk: 10
participants were
excluded. the
result was not
biased by
missing outcome
data. Low risk: The
investigators performing
the measurements and
data analysis were
blinded from the group
assignments” Low risk: The
protocol was not
registered. However,
the pre-defined
outcomes mentioned
in the methods
section seemed
reported. Someconcerns
Mandall
et al.2016[40] Low risk: The randomization
list was generated in
randomization blocks of 10
with stratification according
to gender. The computer-
generated randomization
sequence was concealed
centrally Someconcerns:
Blinding of
participants and
people
delivering the
intervention
cannot be
performed. Low risk: 8
participants were
excluded. the
result was not
biased by
missing outcome
data Low risk: The
investigators performing
the measurements and
data analysis were
blinded from the group
assignments” Low risk: The
protocol was not
registered. However,
the pre-defined
outcomes mentioned
in the methods
section seemed
reported. Someconcerns
Pithon
et al.2021[26] Low risk: Randomization
was performed by a
researcher who was not
involved in the clinical part of
the study, using BioEstat 5.0
software Someconcerns:
Blinding of
participants and
people
delivering the
intervention
cannot be
performed. Low risk: No
dropouts were
reported. Low risk: The
investigators performing
the measurements and
data analysis were
blinded from the group
assignments” Low risk: The
protocol was not
registered. However,
the pre-defined
outcomes mentioned
in the methods
section seemed
reported. Someconcerns
TABLE 6: Appendix 4: Risk of bias assessment for randomized controlled trials according to the
RoB-2 tool
Study
Bias due to
confounding
Bias in the
selection of
participants
for the study
Bias in the
classification of
interventions
Bias due to
deviations
from
intended
interventions
Bias due to missing data
Bias in the
measurement of
outcomes
Bias in the
selection of
the reported
result
Overall
2023 Shaadouh et al. Cureus 15(10): e48064. DOI 10.7759/cureus.48064 16 of 20
O'Regan et
al. 1991
[31] Moderate: The
post-treatment
group was
significantly older
than the other
groups. Serious:
Selection into
the study was
related (but not
very strongly) to
intervention and
outcome Low: Intervention
status is well-definedLow: No
deviations
from intended
interventions
were detectedLow: No dropouts were
reported Serious: No information
about outcome
assessors blinding and
the results may be
influenced by knowledge
of the intervention
received by study
participants Low: Pre-
defined
outcomes
mentioned in
the methods
section
seemed to
have been
reported Serious
Varela et
al. 1995
[39] Moderate: Gender
(female: male
ratio), and a wide
range of
participants’ agesLow: All
participants
who have been
eligible for the
target trial were
included in the
study Low: Intervention
status is well-definedLow: No
deviations
from intended
interventions
weredetected Low: No dropouts were
reported Serious: No information
about outcome
assessors blinding and
the results may be
influenced by knowledge
of the intervention
received by study
participants Low: Pre-
defined
outcomes
mentioned in
the methods
section
seemed to
have been
reported. Serious
Birkeland et
al. 2000
[32] Low: No
confounding
factors detectedLow: All
participants
who have been
eligible for the
target trial were
included in the
study Low: Intervention
status is well-definedLow: No
deviations
from intended
interventions
weredetected Moderate outcome data were
not available for all
participants. Missing data
were not related to the
intervention Serious: No information
about outcome
assessors blinding and
the results may be
influenced by knowledge
of the intervention
received by study
participants Low: Pre-
defined
outcomes
mentioned in
the methods
section
seemed to
have been
reported Serious
Show et al.
2007 [34]Moderate:
Sociodemographic
characteristics Low: All
participants
who have been
eligible for the
target trial were
included in the
study Serious: Intervention
status is not well-
defined Low: No
deviations
from intended
interventions
were detectedModerate outcome data were
not available for all
participants. Missing data
were not related to the
intervention Serious: No information
about outcome
assessors blinding and
the results may be
influenced by knowledge
of the intervention
received by study
participants Low: Pre-
defined
outcomes
mentioned in
the methods
section
seemed to
have been
reported Serious
Jung et al.
2010 [17]Low: No
confounding
factors detectedSerious:
Selection into
the study was
related (but not
very strongly) to
intervention and
outcome Moderate: Intervention
status is well-defined,
and some aspects of
the assignments of
intervention status
were determined
retrospectively Low: No
deviations
from intended
interventions
were detectedLow outcome data available
for all participants. Serious: No information
about outcome
assessors blinding and
the results may be
influenced by knowledge
of the intervention
received by study
participants Low: Pre-
defined
outcomes
mentioned in
the methods
section
seemed to
have been
reported Serious
Seehra et
al. 2013
[35] Moderate:
Different types of
malocclusions and
small sample Serious: the
participants in
this study were
identified as
bullied in the
previous studyLow: Intervention
status is well-definedLow: No
deviations
from intended
interventions
were detectedModerate outcome data were
not available for all
participants. Missing data
were not related to the
intervention Low: No bias in the
measurement of
outcomes was detectedLow: Pre-
defined
outcomes
mentioned in
the methods
section
seemed to
have been
reported Serious
Johal et al.
2014 [13]Moderate: Gender
(female: male
ratio), and a wide
range of
participants’ agesLow: All
participants
who have been
eligible for the
target trial were
included in the
study Low: Intervention
status is well-definedLow: No
deviations
from intended
interventions
were detectedLow: No dropouts were
reported Serious: No information
about outcome
assessors blinding and
the results may be
influenced by knowledge
of the intervention
received by study
participants Low: Pre-
defined
outcomes
mentioned in
the methods
section
seemed to
have been Serious
2023 Shaadouh et al. Cureus 15(10): e48064. DOI 10.7759/cureus.48064 17 of 20
reported
Romero-
Maroto et
al. 2015
[36] Moderate:
Confounding
factors may
detected Serious:
Selection into
the study was
related (but not
very strongly) to
intervention and
outcome Low: Intervention
status is well-definedLow: No
deviations
from intended
interventions
were detectedLow No dropouts were
reported Serious: No information
about outcome
assessors blinding and
the results may be
influenced by knowledge
of the intervention
received by study
participants Low: Pre-
defined
outcomes
mentioned in
the methods
section
seemed to
have been
reported Serious
Nascimento
et al. 2016
[33] Moderate: A wide
range of
participants’ agesLow: All
participants
who have been
eligible for the
target trial were
included in the
study Low: Intervention
status is well-definedLow: No
deviations
from intended
interventions
were detectedLow No dropouts were
reported Serious: No information
about outcome
assessors blinding and
the results may be
influenced by knowledge
of the intervention
received by study
participants Low: Pre-
defined
outcomes
mentioned in
the methods
section
seemed to
have been
reported Serious
Choi S‐H et
al. 2017
[28] Serious: Different
types of
malocclusions with
or without
extraction, and a
wide range of
participants’ ages Low: All
participants
who have been
eligible for the
target trial were
included in the
study Low: Intervention
status is well-definedModerate Low: No dropouts were
reported Serious: No information
about outcome
assessors blinding and
the results may be
influenced by knowledge
of the intervention
received by study
participants Low: Pre-
defined
outcomes
mentioned in
the methods
section
seemed to
have been
reported Serious
Avontroodt
et al. 2020
[24] Moderate:
Sociodemographic
characteristics Moderate: The
sample of
adolescents
was taken
exclusively from
the University
Hospitals
Leuven Low: Intervention
status is well-definedLow: No
deviations
from intended
interventions
were detectedModerate: Proportions of and
reasons for missing
participants were similar
across intervention groups.
The analysis addressed
missing data and is likely to
have removed any risk of
bias. Serious: No information
about outcome
assessors blinding and
the results may be
influenced by knowledge
of the intervention
received by study
participants Low: Pre-
defined
outcomes
mentioned in
the methods
section
seemed to
have been
reported Serious
TABLE 7: Appendix 5: Risk of bias for non-randomized trials according to the ROBINS-I tool
Additional Information
Author Contributions
All authors have reviewed the final version to be published and agreed to be accountable for all aspects of the
work.
Concept and design: Mohammad Y. Hajeer, Ahmad S. Burhan, Ahmad Salim Zakaria , Khaldoun M.A.
Darwich, Ossama Aljabban, Youssef Latifeh
Drafting of the manuscript: Mohammad Y. Hajeer, Rashad I. Shaadouh, Samer T. Jaber, Mowaffak A. Ajaj,
Khaldoun M.A. Darwich
Critical review of the manuscript for important intellectual content: Mohammad Y. Hajeer, Ahmad S.
Burhan, Samer T. Jaber, Ahmad Salim Zakaria , Khaldoun M.A. Darwich, Ossama Aljabban, Youssef Latifeh
Supervision: Mohammad Y. Hajeer, Ahmad S. Burhan, Mowaffak A. Ajaj, Youssef Latifeh
Acquisition, analysis, or interpretation of data: Rashad I. Shaadouh, Samer T. Jaber, Mowaffak A. Ajaj,
Ossama Aljabban
2023 Shaadouh et al. Cureus 15(10): e48064. DOI 10.7759/cureus.48064 18 of 20
Disclosures
Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the
following: Payment/services info: All authors have declared that no financial support was received from
any organization for the submitted work. Financial relationships: All authors have declared that they have
no financial relationships at present or within the previous three years with any organizations that might
have an interest in the submitted work. Other relationships: All authors have declared that there are no
other relationships or activities that could appear to have influenced the submitted work.
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