February 08, 2021

‘Mind the gap!’ … Gaps in the mind. A trial looking at quality of life.

We have previously discussed the research surrounding orthodontic treatment benefits. We pointed out that there was a lack of studies looking at possible socio-psychological and quality of life effects. This issue is important as we have been unable to offer convincing proof of dental health benefit with most orthodontic interventions.

Therefore, it is essential that trials measuring baseline pre-and post-treatment assessments include measures to assess patient-centred benefits. This step ensures that research is relevant not just to us clinicians but also to patients. Furthermore, this information may help to inform treatment and funding decisions within publicly-funded systems.

A team from Brazil did this study. The EJO published the paper.

Impact of oral-health-related quality of life and self-esteem on patients with missing maxillary lateral incisor after orthodontic space closure: a single-blinded, randomized, controlled trial

Matheus Melo Pithon, Eduardo Otero Amaral Vargas, Raildo da Silva Coqueiro, Rogério Lacerda-Santos, Orlando Motohiro Tanaka and Lucianne Cople Maia

Eur. J. Orthod. 2020. doi: 10.1093/ejo/cjaa075

What did they ask?
The authors aimed to assess whether space closure for missing lateral incisors with canine substitution leads to improved self-esteem and quality of life compared to an untreated control over 12 months.
What did they do?

They carried out a two-group randomized controlled trial with a 1:1 allocation (44 participants overall with 47 missing lateral incisors) over a 12-month observation period as follows:


  • Aged 17 to 49 years
  • With one or two missing maxillary lateral incisors
  • Class I, II or III
  • Spacing between central incisor and canine

Intervention Group:

The treated group received fixed appliances to space close for the missing lateral incisors with recontouring of the canines to aid substitution.

Control Group:

The control group did not receive orthodontic treatment during the first 12 months of the study.

Primary outcome(s):

The primary outcomes were Oral Health-related Quality of Life (OHRQoL) and self-esteem.

They used the Oral Health Impact Profile (OHIP-14) questionnaire to assess OHRQoL. This considers oral symptoms, functional limitations, emotional well-being, social well-being, and overall perceptions of general well-being and oral health.

They also used a further validated questionnaire (Rosenberg’s Self-Esteem Scale)  to assess self-esteem. The participants completed the questionnaires at baseline in both groups and again after 12 months in the control group. I had a constructive e-mail exchange with the author,  and they made it clear that they did the last assessment in the intervention group after they had removed the appliances.

What did they find?

The authors undertook several within-group comparisons. I am not sure how necessary these are. I will, therefore try to focus on the between-groups comparisons. Overall, the authors observed an improvement in both self-esteem and OHRQoL in the treatment group. In an adjusted statistical model accounting for demographics, clinical factors and baseline scores, the treated group continued to have better outcomes than the control group. The authors also inferred that participants with higher self-esteem and OHRQoL and lower education level benefitted most from the treatment.

What did I think?

I think that this was an interesting study. I like the fact that the outcomes were simple and of relevance. In particular, the authors limited their analysis to just two outcomes. This step ensured that the study is focused and there is less risk of false-positive, spurious conclusions. In terms of the outcome measures that they used, they used validated questionnaires. However, these do also involve very general measures of quality of life and self-esteem. I do wonder how potent orthodontics may or may not be in affecting this (particularly among adults). There has also been quite a bit of progress in developing more specific, orthodontically-relevant measures in recent years, albeit tailored for adolescent groups.

I also like the subject matter. The decision as to whether to space open or close with missing lateral incisors is a conundrum that we face regularly. I do tend to gravitate towards space closure whenever I can. This treatment reduces the onus on long-term restorative maintenance and may simplify retention to an extent. Nevertheless, there is maintenance involved in preserving the result, and retention is pivotal to long-term success. I wonder whether a more prolonged follow-up might be useful in assessing the long-term benefit of treatment on these patient-related parameters. Also, completion of questionnaires at or soon after removing the appliances risks over-estimating the beneficial effect of treatment in light of the ‘euphoria’ sometimes associated with debonding.

The participants and malocclusion

Furthermore, the study focused on relatively mature participants (17-49 years). Therefore, the evaluation of a younger patient cohort might be more interesting; nevertheless, the study provides us with new and interesting information. I mentioned that they made within-group comparisons. I think that these add little. The finding of a deterioration in self-esteem and quality of life within the untreated control group is surprising. I am struggling to see how this would be anything but stable in an adult population.

A final caveat is that the authors failed to highlight the magnitude of visible space and the presence of primary teeth in the aesthetic zone. They did allude to the presence of space mesial to the permanent canine; however, spacing’s size and location are likely to be pivotal to any patient impacts.

What can we conclude?

In a post-adolescent cohort, orthodontic space closure in the presence of missing maxillary lateral incisors may help to improve self-esteem and oral health-related quality of life in the short term.

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Have your say!

  1. Even though I am on the other side of the pond, I have been greatly influenced over the years by Dr. Zachrisson who strongly recommended space closure for missing laterals even if it meant having to open space mesial of the upper molars to able to close spaces anteriorly. I have followed his lead on that subject and I’m happy to say I’ve never regretted it.

  2. Interesting and potentially very valuable article.
    One question comes to mind: were both the control and intervention group recruited from the pediatric/orthodontic department of the University? I do not have access to a full version of the article to confirm this. But if this were the case, it may indicate that both the intervention and control group patients had some sort of knowledge/awareness of the aesthetic problem caused by a missing lateral incisor which led them to seek a orthodontic/restorative consultation in the first place. In that instance, a question arises whether the self-esteem and perceived oral health-related quality of life of control group is representative of the general population. After all, individuals with missing lateral incisors would most likely seek a medical consultation only if their aesthetic problem is something that they consider an issue.

    The finding of a deterioration in self-esteem and quality of life within the untreated control group may not be that surprising after all, if the control patients were treated in the same way as intervention patients after 12 months (again, I am not able to neither confirm nor to deny this).
    I can imagine having to wait 12 months to have an aesthetic problem fixed may be an inconvenience which could exacerbate a perceived size of the problem

  3. Regarding life style and psycho -social effects post orthodontic tmnt.
    I doubt that my patients / parents would ,happily ,pay my fees and dedicate time and effort unless they saw positive outcome benefits.The market never lies !
    This may be a more reliable marker than any research!
    I stress that such research is still valuable.

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