European Journal of Orthodontics 32 (2010) 43–48
doi:10.1093/ejo/cjp065
Advance Access Publication 2 September 2009

© The Author 2009. Published by Oxford University Press on behalf of the European Orthodontic Society.
All rights reserved. For permissions, please email: journals.permissions@oxfordjournals.org

Quality of life in patients with severe malocclusion before
treatment
Jaana Rusanen*, Satu Lahti**,***, Mimmi Tolvanen** and Pertti Pirttiniemi*,***
Departments of *Oral Development and Orthodontics, and **Community Dentistry, Institute of Dentistry, University
of Oulu and ***Oral and Maxillofacial Department, Oulu University Hospital, Finland

The aim of this study was to determine the occurrence of oral health impacts among patients
with severe malocclusions and dentofacial deformities before treatment. A further aim was to evaluate
the effect of gender or the type of malocclusion on the oral impacts.
The study comprised 151 adult patients who were referred for orthodontic or surgical-orthodontic
treatment to the Oral and Maxillofacial Department, Oulu University Hospital, Finland during the years
2001–2004. The study group consisted of 92 females and 59 males with a mean age of 35.5 years [standard
deviation (SD) 11.5 years, range 16–64 years]. A self-completed Oral Health Impact Profile (OHIP)-14
questionnaire was used to measure oral impacts during a 1 month reference period. The prevalence,
extent, and severity scores were calculated from the OHIP-14. Malocclusions were registered at clinical
examination. The prevalence and mean extent and severity scores were compared among malocclusion
groups and between genders. Statistical significance was evaluated with Mann–Whitney, Kruskall–Wallis,
Chi-squared, and Fisher’s exact tests.
The prevalence of oral impacts perceived fairly or very often was 70.2 per cent. The mean severity and
extent scores were 17.2 (SD 10.5, range 0–45) and 2.5 (SD 2.6, range 0–10), respectively. Physical pain
as well as psychological discomfort and disability were the most commonly perceived oral impacts.
Being self-conscious, feeling tense, having difficulties in relaxing, and being somewhat irritable with
other people were more common in females than in males. No differences were observed in oral impacts
among the malocclusion groups.
Compared with a ‘normal’ population, patients with severe malocclusions report high levels of oral
impacts. Females reported oral impacts more often than males.
SUMMARY

Introduction
In dental research, more emphasis has traditionally been
placed on clinician-driven outcome measures than on
subjective patient-based measures, such as perceived
functional status or psychological and social well-being
(de Oliveira and Sheiham, 2003). The presence of
malocclusion among other oral conditions represents only
one dimension of the complex nature of oral health, and its
clinical assessments have shown only a weak relationship
with the perceived oral health of an individual (Locker
1988, 1992; Dini et al., 2003). While clinician-driven
assessment is in some respects relevant, patient-based
assessment provides more substantive information
concerning the impacts of oral disorders because patients
are considered to be the best persons to judge their own oral
health-related quality of life (OHRQoL; Cunningham and
Hunt, 2001; de Oliveira and Sheiham, 2003).
Patients with severe malocclusions or dentofacial
deformities may report various oral health impacts that
affect their well-being in many ways. A combination of
orthodontics and orthognathic surgery is, in many cases, a
contemporary modality to treat these patients (Mayo et al.,
1991). Patients who seek orthognathic surgery often hope
for a remarkable improvement in their physical well-being

and quality of life. Problems in the facial region in general,
such as those of chewing, speaking, and periodontal disease,
are common physical complaints in patients with severe
malocclusions (Scott et al., 1999). Improvement in aesthetics
is a significant motivating factor to undergo orthodontic or
orthognathic treatment, and some of these patients report
concerns with body image and a low self-esteem or selfconcept (Scott et al., 1999). Temporomandibular joint
problems and external motivation (such as the need to
please others) are also common reasons to seek orthognathic
treatment as well as a need to gain aesthetic or functional
improvement (Cunningham et al., 1995).
According to the review by Cunningham and Hunt
(2001), only limited data are available on orthodontic
patients’ OHRQoL, and changes in quality of life have more
often been studied in relation to orthognathic surgery than
orthodontic treatment. One reason for this might be that
patients undergoing orthognathic surgery have more severe
problems and are thus more likely to benefit psychologically
from improved facial and dental appearance and have a
possible increase in self-confidence compared with patients
treated only by orthodontics (Kiyak et al., 1982, 1984;
Cunningham et al., 2000). O’Brien et al. (1998) stated that
the majority of oral health measures developed in dentistry

44
are not applicable to orthodontic patients because most
indications for orthodontic treatment are asymptomatic and
related to aesthetics, as opposed to features such as pain or
discomfort. For this reason, it is important to use self-report
instruments to determine the patients’ own views and
feelings along with clinical outcome indicators (Cunningham
and Hunt, 2001). These instruments should measure several
dimensions of oral health as described by Locker (1988). Of
the several measures of OHRQoL (Locker and Allen, 2007),
one of the most commonly used is the Oral Health Impact
Profile (OHIP) or its short form OHIP-14. The measure was
based on the International Classification of Impairments,
Disabilities, and Handicaps model of disease and its
consequences (Locker, 1988). OHIP intends to assess the
social impact of oral disorders, i.e. the dysfunction, discomfort,
and disability caused by these conditions (Locker and Allen,
2007). It includes seven sub-scales: functional limitation,
physical pain, physiological discomfort, physical disability,
psychological disability, social disability, and handicap
(Slade and Spencer, 1994). These aspects represent the
hierarchy of impacts that can affect a patients’ daily life
and motivate them to seek orthodontic or orthognathic
treatment.
The purpose of this study was to determine the occurrence
of oral health impacts among patients with severe
skeletal malocclusions who required orthodontic and/or
orthognathic surgery. A further aim was to determine the
effect of gender or type of malocclusion on oral impacts.
Subjects and methods
The study was approved by the Ethics Committee of the
Northern Ostrobothnia Hospital District.
This was a secondary analysis of a data collected for a
longitudinal study. The original study group comprised 249
adult patients, all of whom had severe, diagnosed skeletal
malocclusions with considerable functional disorders and
who were awaiting orthodontic or surgical-orthodontic
treatment at the Oral and Maxillofacial Department at Oulu
University Hospital. From these, 170 patients agreed to
participate in this study, which included a questionnaire
survey and clinical examination. The study was performed
during the years 2001—2004, and the final study group
comprised 92 (61 per cent) females and 59 (39 per cent)
males. The mean age of the participants was 35.5 years (SD
11.5 years, range 16–64 years).
Data were collected using a standardized, self-completed
questionnaire that included a Finnish translation of the
OHIP-14 measure with a 1 month reference period and
questions on age and gender. In the OHIP questionnaire,
subjects were asked, for example, the following: ‘Have you
found it uncomfortable to eat any foods because of problems
with your teeth, mouth, or dentures?’ Five ordinal response
categories were coded with the following values: 0, ‘never ’;
1, ‘hardly ever ’; 2, ‘occasionally’; 3, ‘fairly often’; and

J. RUSANEN ET AL.

4,‘very often’. The Finnish OHIP-14 has been found to be
valid and reliable (Sutinen et al., 2007; Lahti et al., 2008).
The subjects were invited to a clinical examination and
the questionnaire was given to them to fill in at home.
A self-addressed envelope was provided for return of the
questionnaire. The clinical examinations were conducted
by one author (JR) who had undergone training in
stomatognathic examinations before measurements.
Overbite was defined as a vertical overlap of the right central
incisor (mm) and overjet as a horizontal overlap of the right
central incisor (mm). The bite was considered to be open
when there was no occlusal contact (less than 0 mm), and a
deep bite was diagnosed when the overbite was 4 mm or
more. A reverse overjet was registered when the overjet was
less than 0 mm (negative) and an increased overjet when the
overjet was 4 mm or more. A posterior crossbite was
registered when a canine or one or more upper premolars or
molars occluded more palatally than the lower teeth
(transverse discrepancy) and a scissor bite when a canine,
premolar, or molar occluded entirely buccal to the lower
arch teeth. A lateral open bite was registered when there was
no occlusal contact of one or more upper and lower
premolars or molars unilaterally or bilaterally. Sagittal
(antero-posterior) molar relationship was graded using
Angle’s classification of the first permanent molars
bilaterally. When the molar relationship was cusp to cusp, it
was classified as an Angle Class II malocclusion. The oral
measurements were performed using articulating paper
(lateral scissor bite, crossbite, and open bite) and a
periodontal probe (overjet and overbite).
Three variables were calculated from the OHIP-14.
‘Prevalence’ described the percentage of the participants
reporting one or more items ‘fairly often’ or ‘very often’.
The ‘severity’ score (potential range 0–56) was calculated
by summing ordinal values for the 14 items. Higher scores
indicated poorer oral health and disability. The ‘extent’
score (potential range 0–14) was calculated by summing the
number of items reported ‘fairly often’ or ‘very often’.
Those participants who had three or more missing OHIP
items or three ‘don’t know’ responses were omitted from
analysis, and for participants with one or two missing OHIP
items, the values were replaced with the sample mean for
the group. Adequate clinical and questionnaire data were
available for 151 subjects who were included in the
analyses.
Distribution of the prevalence scores and the mean levels
of the extent and severity scores between malocclusion
groups and between genders were calculated. As the
distributions of the extent and severity scores were not
normally distributed, the statistical significances of the
differences between the groups were evaluated using the
non-parametric Mann–Whitney and Kruskall–Wallis tests.
Chi-squared and Fisher ’s exact tests were used to evaluate
the statistical significance of the differences in prevalence
between the groups. Statistical analyses were performed

45

QUALITY OF LIFE AND SEVERE MALOCCLUSION

using the Statistical Package for Social Sciences for
Windows version 16.0 (SPSS Inc., Chicago, Illinois, USA).
Results
The prevalence of oral impacts in this study was 70.2 per
cent. The mean severity score was 17.2 (SD 10.5, range
0–45) and the mean extent score 2.5 (SD 2.6, range 0–10).
Distribution of the patients according to their malocclusions
is presented in Table 1. Of the patients, 3.3 per cent (five)
were using removable dentures.
The percentage distributions of OHIP-14 items reported
occasionally, fairly often, or very often among participants
are shown in Figure 1. Because of problems with their teeth,
Table 1 Distribution of the patients according to their
malocclusions.
Malocclusion

Gender
All

Female

Male

n
Class II
Class III
Lateral crossbite
Lateral scissor bite
Lateral open bite
Open bite
Deep bite (>4 mm)

%

n

%

n

%

67
25
53
41
35
15
81

44
17
35
27
23
10
54

47
11
30
26
18
11
47

51
12
33
28
20
12
51

20
14
23
15
17
4
34

34
24
39
24
29
7
58

mouth, or dentures during the previous month, 67.6 per cent
of the participants had felt pain or discomfort occasionally
36.4 per cent, fairly often 19.9 per cent, or very often 11.3
per cent. Over two-thirds (69.5 per cent) had found it
uncomfortable to eat. Being self-conscious with their teeth,
mouth, or dentures was reported by 69.5 per cent of the
participants and more than a half (57.6 per cent) had
occasionally (27.8 per cent), fairly often (15.2 per cent), or
very often (14.6 per cent) felt tense. Nearly half of the
participants (49 per cent) had felt that life in general was
less satisfying, and 47 per cent had found it difficult to relax.
Despite very severe impacts on their oral health, only 5.3
per cent of the subjects with a severe malocclusion or
dentofacial deformity had been totally unable to function.
Females tended to report oral impacts (fairly often and very
often responses) related to the teeth, mouth, or dentures more
often than males (Table 2). The differences were statistically
significant in the psychological and social dimensions of
OHIP-14, i.e. females reported being self-conscious, feeling
tense, difficulties in relaxing, and being a bit irritable with other
people significantly more often than males.
When comparing prevalence rates among participants
with different malocclusions, statistically significant
differences were found in the lateral crossbite, open bite,
reverse overjet, and Class II malocclusion groups.
Participants with a lateral crossbite had more often been a
bit embarrassed because of problems related to their teeth,
mouth, or dentures (P = 0.039) when compared with patients
with transverse normal dimensions of the lateral teeth.
Subjects with an open bite reported discomfort more often

Figure 1 Percentage distribution of occasionally, fairly often, or very often responses to each Oral Health Impact Profile-14 items among patients with
severe malocclusions before orthodontic or orthognathic treatment.

46

J. RUSANEN ET AL.

Table 2 Percentage of ‘fairly often’ or ‘very often’ Oral Health
Impact Profile-14 responses and the mean extent and severity
scores among males and females.
DHIP items

Gender
All

Trouble pronouncing words
Worsened sense of taste
Painful aching
Uncomfortable eating any foods
Being self-conscious
Felt tense
Unsatisfactory diet
Interrupting meals
Difficult to relax
Been a bit embarrassed
Been a bit irritable
Difficulty doing usual jobs
Life in general less satisfying
Totally unable to function
Extent score
Severity score

Males

Females

P

12
5
31
45
40
30
8
4
19
15
9
9
23
1
2.5
17.2

10
3
22
39
25
10
3
0
5
9
0
5
19
0
1.5
13.5

13
7
37
49
50
42
11
7
28
19
14
11
25
1
3.1
19.6

0.595
0.483
0.053
0.231
0.003
0.000
0.128
0.082
0.000
0.089
0.003
0.216
0.362
1.000
<0.001
<0.001

P values between males and females for the item-wise values from
chi-square tests and for the mean extent and severity scores from
Mann–Whitney tests.

when eating any foods (P = 0.020) than those with a normal
vertical overlap or deep bite. Patients with a reverse overjet
reported being slightly more embarrassed (P = 0.022) and
irritable with other people (P = 0.025) more often when
compared with those with a positive overjet. Class II
malocclusion subjects were less self-conscious in relation
to their teeth, mouth, or dentures (P = 0.043) and had an
unsatisfactory diet less often (P = 0.044) compared with
those with a Class III or other malocclusion. There were no
statistically significant differences in the OHIP-14 severity
and extent scores between different malocclusion groups.
Discussion
Patients with skeletal malocclusions were found to have
high levels of subjective oral impacts in all malocclusion
groups. The total prevalence of reported oral impacts was
greater than 70 per cent. This prevalence is seven times
higher when compared with the results of the National
Health 2000 survey among adult Finns aged 30 years and
older (Lahti et al., 2008), and even higher when compared
with 30 to 44 year olds. Differences in the severity and
extent scores were also greater when compared with those
reported in a nationally representative study among Finns
(Lahti et al., 2008). The the severity score was four times
higher and the extent score eight times higher in the present
study. The severity scores were over two to four times
higher and the extent scores five to seven times higher
compared with those of dentate adults in the United
Kingdom and Australia (Slade et al., 2005). Of the patients

in this study, 3.3 per cent were using removable dentures.
Among adults Finns, the difference in the severity scores
between subjects wearing and not wearing removable
dentures was 6.43 and 2.83, respectively (Lahti et al., 2008).
Thus, the use of dentures did not have a major contribution
to the high severity reported by the patients in this
investigation. In a recent study (Lee et al., 2007), the mean
severity OHIP-14 score of 152 Chinese patients with
dentofacial deformities was 15.0, which is in agreement
with the scores found in the present investigation. Despite
the different reference periods used in Finland (1 month)
and in the United Kingdom and Australia (12 months; Slade
et al., 2005), the mean severity and extent scores of OHIP-14
may be compared with a reasonable degree of confidence
(Sutinen et al., 2007).
However, there are some oral conditions that seem to have
almost equally high oral impacts as severe malocclusions.
For example, patients’ OHRQoL is significantly aggravated
by a dry mouth and xerostomia (Locker 2003; Thomson
et al., 2006). In a study by Ikebe et al. (2007), elderly
Japanese dry mouth and xerostomia patients had an almost
similar severity score (16.8, SD 8.3) as the malocclusion
patients in this study. It seems that a severe malocclusion
usually impairs a patient’s quality of life more than other
oral conditions in the general population. For example, it
was found that patients’ quality of life was impaired by
removable and full dentures but not to the same extent as
by malocclusions (Lahti et al., 2008). Interestingly,
malocclusion patients felt uncomfortable eating at least
twice as often compared with those with dentures, and they
suffered psychological disability related to their oral
conditions nearly four times more often (Lahti et al., 2008).
Painful biting was also more than three times more
common in malocclusion patients compared with those
with dentures.
All 14 OHIP items showed higher scores in malocclusion
patients, and the profile of the item-wise responses was different
from adult Finns (Lahti et al., 2008). Reported physical pain
and psychological discomfort occurred four times more often
among patients with a severe malocclusion than among adult
Finns. Psychological disability, such as difficulty relaxing, was
reported nearly 10 times more often and being a bit embarrassed
over seven times more often in malocclusion patients compared
with Finnish adults. The participants of this study reported
social disability, such as being a bit irritable or having difficulty
doing their usual work, eight times more often and felt life in
general to be less satisfying seven times more often than adult
Finns. This may be a consequence of the multifactorial nature
of the malocclusions and may possibly be the reason to seek
treatment.
All participants in this study had been diagnosed with
severe skeletal malocclusions with considerable functional
disorders. Among the malocclusion groups, differences in
oral health impacts were found in the lateral crossbite, open
bite, reverse overjet, and Class II malocclusion groups. For

47

QUALITY OF LIFE AND SEVERE MALOCCLUSION

example, patients with an open bite reported more often that
they found it uncomfortable to eat, which could be explained
by difficulty in biting. Patients with a reverse overjet felt
more often a bit embarrassed and being a bit irritable with
other people, possibly due to their facial appearance.
Interestingly, participants with a Class II malocclusion
were, in this study, found to be less often self-conscious in
relation to their teeth, mouth, or dentures and had less often
had an unsatisfactory diet compared with those with a Class
III or other malocclusion. In this study, a number of subjects
had combinations of different malocclusions. It is not
always clear to resolve which of those malocclusions caused
subjective oral impacts.
Females reported severe oral impacts more often when
compared with males. This is in agreement with the study of
McGrath and Bedi (2000) on gender variations in the social
and psychological impacts of oral health. They found that
compared with males, oral health had a greater impact on
the quality of life of females, both positively and negatively.
Those authors also stated that females perceived oral health
as enhancing their quality of life, in particular their
appearance, moods, and general well-being. On the other
hand, in the Finnish National Health 2000 survey (Lahti
et al., 2008), there were only minor differences between
females and males, a finding that differs from the results
of the present study. The severity score of males was
slightly higher (4.2 versus 13.5) than that of females (3.9
versus 19.6).
There are many reasons to seek orthodontic treatment.
Aesthetic improvement of appearance is a significant
motivating factor to undergo orthodontic or orthognathic
treatment and is often related to the social well-being of the
patient (Heldt et al., 1982). de Oliveira and Sheiham (2003)
estimated that 80 per cent of orthodontic patients seek
orthodontic treatment due to aesthetic rather than healthrelated or functional concerns, and Mayo et al. (1991)
estimated that dental function was as significant as aesthetics,
while temporomandibular disorders was an additional
reason. Scott et al. (1999) stated that disorders such as
severe pain and psychological, physiological, or social
disabilities are compelling reasons to seek treatment. In this
study, physical pain as well as psychological discomfort
and disability were the most common oral impacts in
malocclusion patients before treatment. In most cases, there
was more than one reason to seek orthodontic treatment.
However, the main aim when seeking treatment is to restore
physiological, physical, social health, and well-being.
As this was a secondary analysis of a data collected for a
longitudinal study, no power calculations were performed.
Some significances in the differences between malocclusions
may have been higher if the study group was larger. The
OHIP-14 measure used was previously found to be reliable
and valid (Sutinen et al., 2007), but intra-examiner reliability
was not assessed. However, all clinical measurements were
performed by one trained author using same instrumentation.

Conclusions
Patients with severe malocclusion or dentofacial deformities
reported significantly higher levels of oral health impacts
than the general population, and it seems that severe
malocclusion impairs patients’ quality of life more than
many other oral conditions. Females tend to suffer more
from oral impacts than males, but there were no specific
malocclusions that caused discomfort or pain affecting a
patient’s well-being more often compared with others.
Address for correspondence
Dr Jaana Rusanen
Department of Oral Development and Orthodontics
Institute of Dentistry
University of Oulu
P.O.Box 5281
FIN-90014 University of Oulu
Finland
E-mail: jaana.rusanen@oulu.fi
Funding
Finnish Dental Society Apollonia.

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