Malocclusion and quality of life


Malocclusion is common and can have a negative effect on oral health. Malocclusion may also have a negative effect on oral health-related quality of life (OHRQoL). While earlier reviews have shown that malocclusion negatively affects OHRQoL more recent reviews have concluded that evidence is lacking for a negative effect.

The aim of this review was to update and earlier review by Dimberg et al (Dental Elf – 26th Sep 2014) and assess the effect of malocclusions in adolescents on OHRQoL, when controlled for potential confounders.


A protocol for the review was registered on the PROSPERO database. Searches were conducted in PubMed, Cochrane Library, CINAHL, Scopus, Web of Science and Google Scholar with PROSPERO and checked for ongoing studies. Randomised controlled trials (RCTs), longitudinal studies, cross-sectional studies (CSS) and cohort studies (CS) involving adolescents aged 10-19years of age with malocclusions and OHRQoL assessed using validated measures and published in English or Scandinavian languages were considered. Initial screening was undertaken by 4 reviewers with subsequent selection undertaken by two reviewers in parallel. Data abstraction was conducted by a single review and cross-checked by the other reviewers. Risk of bias was assessed using the SBU Swedish Agency for Health Technology Assessment and Assessment of Social Services. Tool for non-randomised studies.  Meta-analyses were performed when studies were sufficiently similar. Certainty of evidence was assessed using Grading of Recommendations, Assessments, Development, and Evaluation (GRADE).


  • 13 cross-sectional studies were included.
  • 6 studies were considered to be at low risk of bias and 7 at moderate risk.
  • The prevalence of malocclusion in included studies ranged between 24% and 79%.
  • The Dental Aesthetic Index (DAI) was the most common tool used to rate malocclusion being used in 10 of the 13 studies.
  • 10 studies used the Child Perceptions Questionnaire (CPQ) to assess OHRQoL although different versions of the CPQ were used. One study used the Generic and Condition–Specific Child Oral Impact on Daily Performances index (Child-OIDP) , one the Generic OIDP and one the Oral Health Impact Profile-14 (OHIP-14).
  • 8 studies reported lower OHRQoL in groups with malocclusion compare in those without.
  • 3 of 4 studies comparing malocclusion categories found that OHRQoL gradually decreased when malocclusion increased.
  • Meta-analysis (4 studies, 3672 patients) found that malocclusion had a negative effect on OHRQoL when adjusting for confounders, rate ratio/prevalence ratio = 1.15 (95%CI; 1.12 to 1.18).


The authors concluded: –

There is moderate quality of evidence that malocclusions in adolescents have a negative impact on OHRQoL, after taking relevant confounders into consideration. Future studies should ideally use standardized measures for malocclusion ratings and OHRQoL.


This review aims to update one we have previously covered in one of our blogs (Dental Elf – 26th Sep 2014). Although none of the 6 studies included in that review were included in the updated version.All of the studies included in this updated review had controlled for a range of potential confounder along with general methodological updates.

The authors registered their protocol on PROSPERO and searched a good range of databases including 13 cross-sectional study data with two being derived from longitudinal studies. Both the qualitative and quantitative summaries demonstrated a negative effect of malocclusion on OHRQoL. However, the marked variability across the studies was noted by the reviewers with various methods of assessing malocclusion being used as well as  a range of OHRQoL tools being used for assessment. They also note that most of the malocclusion indexes were designed to assess treatment need.  This highlights the need for common outcome sets to facilitate future evidence synthesis (COMET). The authors also provide a good discussion section on agreement and disagreement with other review along with suggestions for future research.


Primary Paper

Göranson E, Sonesson M, Naimi-Akbar A, Dimberg L. Malocclusions and quality of life among adolescents: a systematic review and meta-analysis. Eur J Orthod. 2023 May 31;45(3):295-307. doi: 10.1093/ejo/cjad009. PMID: 36995692; PMCID: PMC10230246.

Review protocol on PROSPERO

Other references

Dental Elf – 27th Jul 2022

Prevalence of different orthodontic malocclusions

Dental Elf – 11th Dec 2020

Malocclusion, orthodontic treatment and oral health

Dental Elf – 26th Sep 2014

Malocclusion: review finds that it has an adverse effect on quality of life



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