ORIGINAL ARTICLE

Adult orthodontic patients' views regarding dentofacial normality: A qualitative study Nicky D. Stanford,a Tze Bill Ip,b and Justin Durhamc Liverpool and Newcastle upon Tyne, United Kingdom

Introduction: The concept of normality in orthodontic diagnosis and treatment is defined from the clinicians' point of view or derived from concepts developed from observation of “ideal” persons. In-depth appreciation of what a patient views as normal is paramount for effective shared decision making. In this study, we aimed to examine the concept of dentofacial normality in orthodontics from the patient's perspective. Methods: This was a qualitative study of adults attending for orthodontic consultations at a teaching hospital. Semistructured interviews were conducted until data saturation occurred (n 5 15). The data were managed using a framework approach, and recurrent themes were identified. Results: Three main themes were identified in the interviews: the components of dentofacial normality, the impact of dentofacial abnormality, and factors influencing patients' conceptualization of dentofacial normality. The components of normal appearance are apparent in the views of potential adult orthodontic patients. These ideas are formed from personal observations in conjunction with the external influences of family, friends, and the commercial media. There was a biopsychosocial impact of dentofacial abnormality with both enacted and felt stigma playing substantial roles. Conclusions: A normal dentofacial appearance cannot be solely constructed from measureable biologic variables. Patients view normality in terms of features that are acceptable biologically, psychologically, and socially, and there is significant overlap in these domains. Clinicians should be aware that traditionally held concepts of what they believe to be normal or abnormal might not fully represent patients' beliefs. (Am J Orthod Dentofacial Orthop 2014;145:287-95)

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raditionally, the concept of normality in orthodontics is related to biologic variables that are clinician centered. Measured values are derived from groups of subjects with ideal occlusions and facial proportions to provide reference ranges for comparison with patients from relevant populations. The seminal work by Andrews1 examining ideal occlusions is often quoted in the literature with reference to a normal occlusion.2,3 Other authors examining normal occlusions tend to do so using self-derived categories of normality; these naturally tend to differ among articles.4-8

a Senior registrar in orthodontics, Liverpool Dental Hospital, Liverpool, United Kingdom. b Consultant orthodontist, Newcastle Dental Hospital, Newcastle upon Tyne, United Kingdom. c Senior lecturer in oral surgery and orofacial pain, NIHR clinical scientist, School of Dental Sciences, Newcastle University, Newcastle upon Tyne, United Kingdom. All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest, and none were reported. Address correspondence to: Nicky D. Stanford, Orthodontic Department, Liverpool Dental Hospital, Pembroke Place, Liverpool, United Kingdom L3 5PS; e-mail, [email protected]. Submitted, June 2013; revised and accepted, November 2013. 0889-5406/$36.00 Copyright Ó 2014 by the American Association of Orthodontists. http://dx.doi.org/10.1016/j.ajodo.2013.11.016

In assessing someone's facial appearance, the classical canons of facial esthetics place considerable emphasis on ideal transverse, coronal, and sagittal proportions. Similarly, there are a considerable number of different methods to measure the soft-tissue profile. Many of these techniques have no firm evidence base.9 Those who claim an experimental basis tend to use early cephalometric data of clinician-deemed normal subjects or population averages of unrepresentative samples.10-13 For hard-tissue skeletal measurements, numerous cephalometric analyses have been developed. An example of this is the Michigan standard values, which are argued to be a suitable representation of normal cephalometric variables in persons with ideal facial and occlusal proportions, although the authors rightly stated that an infinite number of dentoskeletal relationships can result in a balanced outcome in any patient.14 As such, the argument is often that it is erroneous to treat the lateral cephalogram and not the patient it represents.15 It is clear that guidelines for dentofacial norms, although useful, are not prescriptive. Only through careful examination of each patient can suitability for a 287

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particular treatment be ascertained because there is considerable variation in the ability of people to cope with deviations from the esthetic norm.16 Knowledge of what each patient perceives as normal is paramount before treatment planning. However, little research has been carried out to explore our patients' views with regard to normal dentofacial features. In the dental literature, it has been argued that defining normality from the traditional clinician-based standpoint risks recognizing a patient as “abnormal” or in need of treatment when in fact that person might not think that any treatment is necessary.17 The converse of this, basing the decision to treat on wholly patientdefined norms, would also be erroneous. The decision to progress to treatment should not be derived from the patient's demand or the clinician's paternalism; instead, shared decision making should be adopted whenever possible.18 For shared decision making to be effective, however, both persons need to understand the other's perceptions. Most important in this is that the clinician is aware of and able to understand the concepts of normality that the patient may have formed. The concept of a perceived “normal” state has been explored in the medical literature using qualitative methodology and was found to be prevalent at a biopsychosocial level in patients suffering from a range of conditions.19-22 The concept has only recently been explored with patients with oral conditions, specifically those who were receiving dental implants.23 It was found that these patients had an overriding desire to regain normality through relief of their symptoms: poor masticatory function and poor dental appearance. Traditional quantitative research methodologies are unsuited to investigating this subject because of their deductive approach that does not favor the emergence of new perspectives.24 When used improperly, these techniques can lead to the misinterpretation of decontextualized data and the oversimplification of human behavior.25 Qualitative research aims to develop “an in-depth and interpreted understanding of the social world, by learning about people's social and material circumstances, their experiences, perspectives and histories.”26 To investigate patients' views about normal dentofacial features, qualitative methods are ideal because they are suited to exploring complex phenomena or areas not amenable to quantitative research owing to a lack of previous research on the subject.27 In this study, we aimed to examine the concept of dentofacial normality from the orthodontic patient's perspective using qualitative methodology.

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MATERIAL AND METHODS

A favorable ethical opinion was obtained before patient recruitment (United Kingdom Northern and Yorkshire regional ethics committee reference 11/NE/0274). The subjects were recruited from those attending for an orthodontic consultation after a referral regarding a dentofacial abnormality. They had to be English-speaking patients over 18 years of age. Subjects were excluded if they had congenital craniofacial abnormalities (eg, syndromic deformity or clefts of the lip or the palate). Purposive sampling was used to derive a depth and a breadth of opinions from groups of patients who might be expected to hold differing views of normality. The sampling criteria were defined according to the treatments the patients were willing to undergo. For example, it was assumed that those willing to undergo invasive orthognathic surgery to correct their appearance might have a different opinion of what constitutes a normal dentofacial appearance compared those who required surgery to fully correct their facial abnormality but were unwilling to pursue this and desired treatment involving dentoalveolar camouflage instead. It was considered necessary to include men and women of differing ages since views on normality may differ between the sexes and along the age spectrum. The sample criteria included patients who (1) wanted to pursue complex interdisciplinary treatment (eg, fixed appliances with orthognathic surgery), (2) wanted to pursue compromise treatment (eg, masking a crowded and skeletal Class II malocclusion with relief of crowding and partial overjet reduction), (3) wanted to pursue routine fixed appliance treatment, or (4) declined treatment on grounds other than finances. The one-to-one interviews were semistructured and conducted by a trained interviewer (N.D.S.) using a flexible, evolving topic guide. This allowed the discussions to be focused while allowing scope for deviation from the guide if necessary to fully explore each patient's ideas and beliefs. This guide was based on professional opinions, the literature regarding what constitutes a normal occlusion, and the biopsychosocial health benefits that might be gained from resolving an underlying malocclusion. The interviews were digitally recorded, anonymized to protect patient confidentiality, professionally transcribed verbatim, and then checked for accuracy against the original recording. Analysis broadly followed the principles of the constant comparative method and was concurrent with data collection.28 Two trained researchers (N.D.S. and J.D.), with differing clinical backgrounds, analyzed and coded the data independently to ensure that any emerging theory was robust and valid29; one was a

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postgraduate orthodontic student trained in qualitative analysis, and the other was a senior lecturer in oral surgery with extensive experience in qualitative research. A framework approach was used to help organize the data, which were inputted into an Excel spreadsheet (Microsoft, Redmond, Wash).30 Through this technique, initial themes or concepts that permeated the subjects' interviews were ascertained. These themes were then developed into the framework where relevant extracts from the interview were inserted. Table I shows an extract of the large framework used for this study. An explanatory theory was then derived from the data by looking for clustering in the responses from all participants. This process ran concurrently with the data collection process as themes became apparent, rather than once active data collection was complete. Interviews were continued until data saturation: ie, when no new themes or ideas were expressed. RESULTS

Data collection and analysis continued until data saturation had been reached. This occurred after 15 interviews. To illustrate how patient perceptions were used to support the developing theory, representative quotations from the interviews are used to illustrate and support the theories presented. Any sections in brackets are for explanatory or contextual purposes only and were not part of a patient's response. The patients are further described in Table II. The concept of dentofacial normality was explored with each patient, and 3 main themes emerged: the components of dentofacial normality, the biopsychosocial impact of dentofacial abnormality, and factors influencing patients' conceptualization of dentofacial normality. In each main theme, subthemes emerged. There were complex interactions and overlapping of the themes and subthemes that provided detailed insight into orthodontic patients' views on what constitutes dentofacial normality, how their perceived abnormality affects their everyday well being, and how these concepts are shaped and formed throughout their lives. The components of dentofacial normality

For the components of dentofacial normality, there was a general belief that a normal appearance would constitute a certain degree of uniformity in relation to the population as a whole even with mild irregularities. An obviously visible difference would lead to being seen as “abnormal” either by themselves or by others, and this would be negative.

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Every photograph I had taken they [the prominent maxillary canines] were just there and you couldn't get away from it and it just, it looked odd so I just decided that enough was enough. (Patient 6)

There was an acknowledgment that it is unrealistic to expect that everyone should look identical, and there would naturally be some esthetic variation that is acceptable as long as it is not an uncommon deviation. Everybody's different . . . Uh . . . and it would be a really sad world if we all looked exactly the same. (Patient 11)

Occasionally, an undertone of concern was expressed that the occlusal trait the patient perceived as requiring treatment might in fact be normal. The fine line between what was a true abnormality that required treatment and what was actually a normal trait that would be altered only for superficial reasons was evident. [Getting my teeth straightened is] probably a bit of vanity I suppose, like. Uh . . . I just seem to see . . . see other people with nice teeth and [I wondered] if something could have been done. (Patient 10)

When patients related to their own concerns, they fixated on a particular dentofacial feature that they thought was not normal and subsequently the reason for seeking an opinion on its treatment. This was demonstrated about increased gingival show, grossly incompetent lips, increased overjet, traumatic overbite, reverse overjet with a prognathic mandible, retrognathic mandible, dental crowding, dental spacing, changes in the dental appearance over time, and anterior open bite. Some patients openly discussed how features lacking in any visible abnormality were more subjectively attractive. I think it's just nicer looking and my personal feeling is that straight teeth look better, look nicer, they give you a nicer smile . . . make you more attractive I think. (Patient 14) The reported biopsychosocial impact of dentofacial abnormality

From a biologic standpoint, patients described what was normal from the perspective of their own malocclusions. Pain was reported as one abnormal feature that motivated them to seek a consultation about their condition. Pain is not a feature commonly associated with malocclusions, and exploring the data further illustrates that this pain tended to be related to a traumatic overbite, the discomfort and difficulty of having to manipulate their jaw to speak or chew, or a pain of dental origin. It was reported that masticating in an effective manner was often not straightforward and could involve manipulation of the jaws to achieve what was assumed to be a normal biting or chewing pattern.

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Table I. Extract from tabular framework used to determine the emergent themes Emergent themes What is dentofacial normality? Patient number 12

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Quotation with reference “My teeth shouldn't be there and you know that when me [my] mouth's at rest they shouldn't be, they shouldn't be there [visible between my lips].” line 276 “They [maxillary front teeth] do bother us a little bit but nowhere near as much as they used to. They have come down an awful lot [since thumbsucking habit has stopped], which is obviously good but they do still bother us.” line 83

Social impact of abnormality

Interpretation Normal appearance 5 competent lips.

AOB reduced over time but still not normal.

Outcome of consultation Age Complex Compromised Routine Refused (y) Sex tx tx tx tx 31 F U 21 F U 18 F U 22 M U 24 M U 18 M U 42 F U 20 M U 25 F U 53 M U 69 F U 45 F U 30 F U 20 F U 30 F U

Tx, Treatment; F female; M, male.

When I eat I have to push my jaw back[wards] because my back teeth don't join. (Patient 1)

Some who reported difficulty in mastication also alluded to a degree of felt (by the sufferer) or enacted (upon the sufferer) stigma. To combat any enacted stigma, their response was to either cover up their mouth or modify their behavior so that they did not have to disclose what they felt was their stigmatizing condition to others. If I'm eating in public, trying to eat a sandwich is really difficult at times [due to an increased overjet with incom-

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Interpretation Patient feels appearance is noticed by others.

Difficulty with normal social interactions due to appearance.

plete overbite]. Especially if it's meat . . . I don't eat meat sandwiches in public. (Patient 11)

Table II. Purposive sample characteristics

Patient number 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15

Quotation with reference “People do notice, you know, that there's something wrong [asymmetry due to maxillary canine adjacent to the maxillary central incisor unilaterally]. It's not right, you know.” line 98 “If I was to laugh or to smile I think I would instantly think about, ‘Oh, don't laugh like that because you can see my teeth’, do you know what I mean?” line 222

On a psychological level, low levels of self-confidence because of a dentofacial abnormality were described in this study. These negative feelings were often reported as drivers toward seeking treatment. There would be certain things where I wouldn't be as confident because of that [crooked teeth on smiling] and I know that if I'd had that corrected a lot of years ago that certain situations, yeah I probably would have been a lot more confident. (Patient 1)

These expressed low levels of self-confidence were mirrored by the participants' self-consciousness about themselves. This was described as manifesting when around others who had what the patient considered to be normal facial features. In these situations, it was believed that their perceived abnormality became more noticeable, enhancing the chances of enacted stigma. I'm really conscious that I'm talking to them, you know . . . especially if they've got lovely teeth I'm thinking, what will they think of me? (Patient 11)

The data also contain examples of those who said that they became aware of being abnormal because they were getting teased about their appearance as a child. In a way that . . . I suppose it harks back to childhood when you get like kind of teased about them [her teeth] because that . . . that's where it's fixed in that it wasn't normal to have me [my] teeth as they, you know, me [my] teeth aren't normal because you've been teased about them, you know, and I suppose that in my mind is how it's not normal. (Patient 12)

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Patients also clearly articulated that their deviation from a dentofacial normal had a negative effect on their social well-being. Again, this mainly related to the stigma they felt during social interactions. There was a common feeling reported by the subjects that it was natural to make assumptions about a person because of his or her appearance and that, because appearance was not normal, the person would be judged negatively. I know meself [sic] how I . . . how you view people and judge people based on appearances and you really don't mean to, [it's] subconscious. So you know that it happens, so therefore you know people are doing it to you, so then you suddenly realize, howay [colloquial exclamation], appearance does, it does matter and it will matter. (Patient 4)

These beliefs about felt stigma subsequently lead to a conscious awkwardness when trying to socially interact with unfamiliar people. I don't like socialising with people unless I really, really know them 'cos I think they’re looking at me [my] teeth. (Patient 5)

This felt stigma regarding their appearance has a subsequent effect on the patients' behavior. They try to cover up the abnormality, adopting selective concealment of their facial features in the hope of minimizing any negative labeling because of their appearance. I'm conscious all the time and constantly bringing me jaw forward . . . as I say you get the impression, people get the impression . . . that you give off the impression that you're a bit gormless [colloquialism for lacking intelligence and vitality]. (Patient 4)

There were also instances of patients expressing the desire to conceal their abnormality but unable to do so because of their evident facial features. This was in the belief that the stigma attached to an abnormal appearance would be reduced if it could be masked. Even if a person is wearing a fixed appliance, it can cause the abnormal appearance to be more socially acceptable because the person is under treatment. I'm not normal because I've got a dodgy ticker, I've got a hearing impairment . . . but I just, I think you wouldn't know about that if you looked at me from afar. You wouldn't know that I was deaf, you wouldn't know I had a scar, you wouldn't know anything, but I think you'd notice the teeth. . . . When I get my brace I'll be more inclined to smile because people will think at least she's doing something about her minging [colloquialism for ugly] teeth. (Patient 3)

Factors influencing patients’ conceptualization of dentofacial normality

Professional opinion can play an overarching role when the patient, as a child, was not referred for an

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orthodontic opinion because of the insistence of a general dentist. The role can also be the opposite: recommendations in later life can result in treatment being sought when the patient was unaware of the treatment options available. When you're younger you'd say to your parents and the response from my mum would always be “well the dentist isn't seeing it as a big thing, you mustn't need one.” (Patient 1)

The views of family members and peers might also influence the patient's views regarding a normal appearance. This can be by confirmation of the person's concerns regarding appearance and encouraging the person to seek treatment. My dad's mother's proper ugly, like she's really ugly [due to her Class III features] . . . my mum says . . . “I don't want [patient 3] to turn around when she's like 90 and [ask] why didn't you do anything about my teeth?” (Patient 3)

The contrary can also be true: family members reassure the person that although they might believe there is a visible abnormality, they do not require it to be treated and do not look abnormal. When I used to complain to my husband I used to go on and on for him and he'd say “there's nothing wrong.” (Patient 11)

However, positive reassurance does not remove the innate belief when a person perceives that he or she has an abnormal appearance. When I told my friends like “oh I'm getting a brace” they were like “why when you've got straight teeth?” and I'm like “I haven't got straight teeth, if you look properly they're not straight.” (Patient 14)

How each person views what is normal does not just come from interactions with other individuals. The widespread prevalence of the commercial media, either in print or through the Internet, appears to be a pervasive influence in forming views of what is normal. Magazine articles and promotional brochures can demonstrate to patients that situations analogous to theirs are “abnormal” and can subsequently be treated to appear more “normal.” Looking at before and after pictures [on the Internet] of what people have got and I'm thinking “my word their smile was a hell of a lot worse than mine and see the results they're getting, then there's got to be something that can be done for mine.” (Patient 1)

There can be a strong influence of media portrayals of not just normality, but what should be considered perfect or ideal. You're aiming for something that you think, well you think and society thinks, is the right way to be but in reality,

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generally the average person isn't like that and it goes for the same with a lot of things and not just your teeth. (Patient 8)

However, accepting this media depiction about what should be considered normal or socially acceptable can lead some people to seek treatment to aspire to this ideal. I think it's about looking socially acceptable. It's like, Cheryl Cole has got perfect teeth, Angelina Jolie has perfect teeth, Jennifer Aniston has perfect teeth. (Patient 3)

The data also reflect the view that the depiction of dentofacial features in the popular media can be “fake” and not normal. This can even lead to people with teeth that are considered “too perfect” to have an unattractive appearance. Well I try not to take too much attention on what's going on with the media because anyone who's an actor or a model or something in the media has probably had thousands of pounds worth of jobs done to their teeth anyway so I wouldn't try and compare myself to them sort of people. (Patient 8) I mean Simon Cowell's teeth are just, I don't like them because they're just, you can tell that they're . . . they're too perfect. They're too white. They're just, you can tell they're not, well I think they're not real. (Patient 7)

How patients arrive at a view of what is normal also takes into account how they view themselves and others. It might be through the critical observations of family and friends or by viewing how their own appearance has changed from what was previously considered a more normal appearance. Some of my friends have got straight teeth and I just think they look nicer, they look – they've got a nicer smile than people that don't have straight teeth. (Patient 14) The way they are now is more normal because now they're settled [after late incisor crowding] . . . but for me that was normal getting them fixed [with fixed appliances as a child]. (Patient 9) DISCUSSION

Recently published studies have demonstrated the value of qualitative research in orthodontics. The systematic analysis of patient interviews using robust and tested methodologies has provided valuable data on topics such as the motivation behind patients seeking treatment for a dentofacial deformity, along with their expectations for the outcome of such treatment.31,32 Through the qualitative research methodology in this study, valuable insight has been gained into potential orthodontic patients' views about what is dentofacially “normal.” Although the concept of normality is often seen as an abstract idea that is hard to specifically define, all those

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interviewed clearly explained their ideas and thoughts as to what constituted normal dentofacial features.33 Their explanations related mainly to the features of their own malocclusion and how their resolution would return the patient to a state of normality. However, they also discussed an overarching perception of what is dentofacially normal. It is pertinent to remember that even though a person has a complaint regarding an aspect of his or her appearance, this might not always be a clinical abnormality. Body dysmorphic disorder can present in a patient with a preoccupation with an imagined defect in physical appearance where none exists. This condition has been demonstrated in adults who come for routine orthodontic assessment.34 However, all the patients interviewed for this study had a clinically definable malocclusion relating specifically to their complaint and were subsequently deemed suitable for treatment. Normal appearance was not seen as an immutable constant in this cohort, and minor irregularities are acceptable within normality. An undertone of concern was expressed that the occlusal trait the patient perceived as requiring treatment might be normal. The fine line between what was a true abnormality that required treatment and what was actually a normal trait that would only be altered for superficial reasons was evident. This argument is commonplace among practitioners of cosmetic surgery: is it part of a “beauty industry” or does it provide a real and much-needed service to a wide range of patients?35 As such, it is important to examine the potential for abnormal features to impact on daily life. Modern concepts of health care view a patient's health in terms of the biopsychosocial model.36-38 This model has been shown to have a role in what is considered normal from the accounts of those suffering from a range of conditions.19-23 Our data illustrate how patients referred to an orthodontic department perceive their abnormality and richly describe the wide-ranging biopsychosocial impacts of perceived “abnormal” dentofacial features on the patient. The negative effects described were biological, psychological, and social, with significant overlaps between these domains. Why these effects manifest is rooted in each patient's view of what constitutes normal dentofacial features. The opinions of dental professionals, friends, and family, along with the influence of commercial media and personal contemplation of themselves and others all play roles in this. It is not possible to state that 1 area has overriding importance because the data show that some people value media representations of appearance, whereas others see their close relatives' views as more critical. However, it is important to understand the areas

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that can play a role in these conceptualizations to deepen the understanding of how orthodontic patients come to their own views. One overarching cause linking the negative effects the participants described was the stigma associated with dentofacial abnormality. Stigmatizing conditions are defined as those that set their possessors apart from “normal” people and mark them as socially unacceptable persons.39 Goffman40 suggested that a stigma exists as a consequence of a given medical condition and is related to the social interactions of the stigmatized persons and how they perceive themselves. He described how, whenever there is a significant difference between a person's ideal of what a normal person is like and the person's actual identity, then negative consequences are likely to follow. Scambler and Hopkins41 made the distinction between enacted stigma and felt stigma. Enacted stigma refers to incidences of discrimination on the grounds of inferiority of those with a given condition. Felt stigma refers principally to the fear of enacted stigma, alongside the shame of suffering from that condition. For those who do view themselves as possessing a dentofacial abnormality, the concepts of felt and enacted stigma would seem to pervade throughout day-to-day existence. This is mainly due to the inability to hide the face in everyday life, whereas other potentially stigmatizing conditions can be masked. Some of our subjects explained their difficulties in chewing, which they related to their abnormal occlusion. This was not unexpected because a recent systematic review of the literature found that malocclusion has been shown to influence masticatory efficiency.42 However, stigma was also involved in relation to difficulties in effective mastication, especially when eating in public. The potential psychological effects of patients perceiving that they have an abnormal appearance are evident in the data we collected. The orthodontic literature describes how, although persons with a severe malocclusion can possess an abnormal psychological status, they are no more likely to demonstrate a clinically abnormal psychological state than counterparts with a more normal occlusion.43 It may be that any psychological effect presents at a subclinical level, but it is impossible to tell whether these feelings are directly related to abnormal dentofacial features, even though that may be how the patient perceives them. The negative psychological effects of bullying are well documented.44 A cross-sectional study reported incidents of bullying in adolescents attending for an orthodontic consultation and the strong association between malocclusion and bullying.45 Therefore, it is unsurprising that this form of enacted stigma was

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described in our sample. Interceptive orthodontic treatment of malocclusion can eliminate the recurrence of reported bullying.46 It might subsequently reduce the stigma derived from the visible abnormalities. The effects of appearing normal during social interactions are more complex. Cross-sectional research into views of adolescents and young adults regarding the appearance of a range of occlusal abnormalities consistently demonstrates that images of those with a normal dentofacial appearance are viewed more positively with regard to their attractiveness, intelligence, and personality.47-49 The data collected support these assertions because those interviewed reported a belief that society attaches stereotypical labels to the appearance of a person with an unresolved malocclusion that are independent of how the patient actually views himself or herself. However, although these results are descriptive for our sample, they cannot be seen as representative of a given population (ie, all potential orthodontic patients). The aim of qualitative research is to provide an in-depth description into the themes underlying a research question. These data can be used to derive questionnaires to allow for quantitative assessment across a more representative sample.50 This methodological sequencing is appropriate for the subject investigated in this study because there is a lack of literature on the topic. Even so, it could be argued that this topic should be addressed across a more varied demographic sample before using quantitative methodology. For example, our cohort was mainly female, and all participants were white. Although we found a relatively homogenous data set regarding the themes underlying dentofacial normality, further qualitative investigation in a more diverse population might be warranted. Overall, because no other researchers have investigated the concept of a normal dentofacial appearance from the perspective of the potential orthodontic patient, these results could have implications for orthodontic treatment as a whole. Given the array of methods used to quantify normality and to diagnose and treat these patients, the lack of such research was an anomalous situation. Subsequent investigations into the perceptions of child patients might also be appropriate to elucidate this concept further. This should be done with care so as not to cause distress to immature subjects by labeling them as “abnormal.” Current methods of determining the treatment needs of orthodontic patients might require further investigation in light of these findings. Since indexes of need are derived from clinician-based views of a

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“normal” occlusion, it is unsurprising that there is discord between the clinician and the patient regarding malocclusions that need treatment.51 If the treatment provided is to benefit the health of a patient considering the biopsychosocial model, it might not be appropriate to solely use these indexes to ration treatment in a health care system. Investigations should also be undertaken into the role of stigma in people with a malocclusion. This work could enrich the information provided by clinicians to their patients regarding the potential benefits from treatment to correct a malocclusion. CONCLUSIONS

The data collected demonstrate the following in adults who attend for an orthodontic consultation. 1. 2.

3.

4.

The concept of a normal dentofacial appearance is apparent. The constructs of normality consist of personal experience and can be influenced by external factors such as opinions of dental professionals, views of friends and family, and the portrayal of appearance in the popular media. A normal appearance seems to include biological, psychological, and social elements. Patients do not seem to recognize abnormality solely as discrete variations from a prescribed “normal” occlusion. Deviations from normal facial features result in a biopsychosocial impact in which stigma appears to play a considerable role.

The potential for discord between the clinician's and the patient's views of normality and subsequently what is deemed to require treatment should be explored. The role of stigma in both the need and the desire for treatment requires further investigation. REFERENCES 1. Andrews LF. The six keys to normal occlusion. Am J Orthod 1972; 62:296-309. 2. Oltramari-Navarro PV, Janson G, de Oliveira RB, Quaglio CL, Castanha Henriques JF, de Carvalho Sales-Peres SH, et al. Tooth-wear patterns in adolescents with normal occlusion and Class II Division 2 malocclusion. Am J Orthod Dentofacial Orthop 2010;137:730.e1-5. 3. Trivino T, Siqueira DF, Andrews WA. Evaluation of distances between the mandibular teeth and the alveolar process in Brazilians with normal occlusion. Am J Orthod Dentofacial Orthop 2010;137: 308.e1-4. 4. Chen LL, Xu TM, Jiang JH, Zhang XZ, Lin JX. Longitudinal changes in mandibular arch posterior space in adolescents with normal occlusion. Am J Orthod Dentofacial Orthop 2010;137:187-93. 5. Thilander B. Dentoalveolar development in subjects with normal occlusion. A longitudinal study between the ages of 5 and 31 years. Eur J Orthod 2009;31:109-20.

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