Research Articles (Orthodontics)

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Perceptions of South African plastic surgeons regarding academic education in the field of cleft lip and palate
(Wolters Kluwer Medknow, 2024-01) Ghabrial, Emad; Madaree, Anil; emad.ghabrial@up.ac.za
BACKGROUND: Historically, South African plastic surgeons (PSs) have been managing cleft lip/ palate (CLP) and craniofacial anomalies (CA). PS lead CL/P teams globally where the need arises. The complex, lengthy nature of CL/P management requires holistic services and collaboration between disciplines. Academic education should provide in-depth knowledge, interdisciplinary participation, and clinical exposure to field experts. OBJECTIVES: An investigation into exposure and knowledge of South African PS regarding management of CL/P. An opinion from practicing PS about academic educational needs for working with CL/P patients. METHODS: Online survey and telephone interviews (a structured questionnaire) investigating opinions of PS in CL/P to determine satisfaction with the adequacy of academic education and perceived needs. RESULTS: The questionnaire was completed by 41% of practicing PS from Medpages health‑care provider database. Most respondents (63.3%) were between 30 and 49. Of them, 74% showed good general knowledge of CL/P. However, 76.5% acknowledged limited clinical training and exposure in this field, preventing them from adequate services provision to CL/P patients. Only 41% offered primary and/or secondary treatment to CL/P patients and 40% had participated in interdisciplinary teams. All agreed on the need for a dedicated training program(s) in CL/P management. The majority recommended subspeciality training through a clinical fellowship or a degree course. CONCLUSION: PS postgraduate academic training and clinical exposure are limited in the CL/P field. An educational strategy should be established to meet the needs of PS providing CL/P care. Part-time clinical fellowship and/or degree courses would prepare them adequately for a career managing CL/P and CA patients.
The feasibility and acceptability of a mobile application for oral health education among adults in Rwanda
(Dove Medical Press, 2024-09) Nzabonimana, Emmanuel; Malele-Kolisa, Yolanda; Hlongwa, Phumzile
BACKGROUND : Mobile technology health application (mobile Apps) can assist people manage their health and wellness, encourage healthy lifestyles, and provide valuable information whenever necessary. OBJECTIVE : This study aimed to evaluate the feasibility and acceptability of a mobile App for oral health education among adults in Rwanda. METHODS : This was a descriptive cross-sectional study. A total of 111 adult participants evaluated the acceptability and feasibility of the BrushDJ mobile App after using it for three months. At the end of this period, an online survey was conducted using a structured questionnaire consisting of questions on demographics, habitual oral health, assessing acceptability, and assessing the feasibility of the mobile App. Descriptive statistics were performed to analyse demographic characteristics, the feasibility and acceptability of the mobile App. Bivariate analysis using the Chi-square test was performed to detect significant associations amongst the variables. RESULTS : The response rate was 81% (n=90) of 111 participants who took part in the study, with the majority of participants 44.44% (n=40) aged between 18 and 27 years old. Just over half of the participants were male 51.11% (n=46). The mobile App was found to be highly acceptable (87.78%; n=79) and considered highly feasible (84.44%; n=76) by most of the participants. The differences in acceptability and feasibility across education levels were statistically significant (p=0.000 for acceptability and p=0.038 for feasibility). CONCLUSION : The study revealed that the mobile App for oral health education (BrushDJ) was highly acceptable and feasible among the participants. The mobile App had a user-friendly interface and comprehensive guidance on oral hygiene procedures facilitated by its diverse and well-integrated functions.
Audit of dental record-keeping at a university dental hospital
(AOSIS, 2023-12-20) Moshaoa, Mpule Annah Lerato; Taunyane, Keitumetse; Hlongwa, Phumzile; mpule.moshaoa@up.ac.za
BACKGROUND : Good record-keeping is fundamental in clinical practice and essential for practising dental practitioners and those in training. AIM : This study aimed to evaluate the level of compliance with clinical record-keeping by undergraduate dental students and staff at a university dental hospital. SETTING : The selected study setting was the Admissions and Emergency section at a university dental hospital. METHODS : A retrospective, cross-sectional review was undertaken of 257 clinical records. The CRABEL scoring system was used to evaluate 12 variables. The 12 variables included: patient name, patient hospital number, date of examination, patient main complaint, medical history, dental history, proposed treatment, proposed procedure for next visit, patient consent signature, treatment and treatment codes, student name and signature, clinical supervisor name and signature. STATA® 13 was used for descriptive analysis and all tests were conducted at 5% significance level. RESULTS : The median CRABEL score was 87 and interquartile range (IQR: 70–92). A CRABEL score of 100 was achieved by the students in the variable patient main complaint, indicating a 100% compliance with this variable. Other variables such as signature of supervisors showed poor compliance. The CRABEL scores showed no statistically significant difference (p = 0.86) between the students and clinical supervisors. CONCLUSION : The overall audit showed that there was poor compliance with record-keeping. CONTRIBUTION : The study highlights the importance of good record keepings so that key information can be accessed for proper diagnosis and treatment of the patient. An electronic filing system presents an alternative manner of documenting medical records.
Incidental pathologic findings from orthodontic pretreatment panoramic radiographs
(MDPI, 2023-02) Hlongwa, Phumzile; Moshaoa, Mpule Annah Lerato; Musemwa, Charity; Khammissa, Razia Abdool Gafaar; phumzile.hlongwa@up.ac.za
Panoramic radiography is frequently performed for new patients, follow-ups and treatment in progress. This enables dental clinicians to detect pathology, view important structures, and assess developing teeth. The objective of the study was to determine prevalence of incidental pathologic findings (IPFs) from orthodontic pretreatment panoramic radiographs at a university dental hospital. A retrospective cross-sectional review was conducted of pretreatment panoramic radiographs, using data collection sheets with predefined criteria. Demographic data and abnormalities (impacted teeth, widening of periodontal ligament, pulp stones, rotated teeth, missing teeth, unerupted teeth, crowding, spacing, supernumerary teeth, and retained deciduous teeth) were reviewed. SPSS 28.0 was used to analyze data with statistical tests set at a 5% significance level. Results: One hundred panoramic radiographs were analyzed with an age range of 7 to 57 years. The prevalence of IPFs was 38%. A total of 47 IPFs were detected with altered tooth morphology predominantly (n = 17). Most IPFs occurred in males (55.3%), with 44.7% in females. A total of 49.2% were in the maxilla and 50.8% in the mandible. This difference was statistically significant (p < 0.0475). Other abnormalities were detected in 76% of panoramic radiographs; 33 with IPFs and 43 without. A total of 134 other abnormalities detected showed predominantly impacted teeth (n = 49). Most of these abnormalities were in females (n = 77). Conclusions: The prevalence of IPFs was 38%, predominated by altered tooth morphology, idiopathic osteosclerosis, and periapical inflammatory lesions. Detection of IPFs from panoramic radiographs underscored the importance for clinicians to examine them for comprehensive diagnosis and treatment planning, especially in orthodontics.
Buccal corridor changes in orthodontically treated extraction and non-extraction Class 1 patients
(South African Dental Association, 2022-06) Choma, Ntwampe M.; Madiba, Thomas Khomotjo; Sethusa, Peter M.S.
BACKGROUND : Patients seek orthodontic treatment mainly to improve their facial aesthetics and obtain an acceptable smile. It is purported that orthodontic extraction treatment may result in narrow buccal corridors which in turn may lead to unaesthetic smile AIM : To determine if the dimensions of the buccal corridors are influenced by extraction or non-extraction treatment in Class 1 patients DESIGN : Retrospective record-based study conducted between 2012 and 2017 at University of Pretoria Orthodontic department MATERIALS AND METHOD : Smile pictures of pre- and post-treatment Class 1 patients treated with or without premolar extractions were matched. Buccal corridors between the two groups were measured by measurement of visible maxillary dentition and oral aperture dimensions. Data analysis included frequencies and correlations using chi-square test, with a significance level set at p<0.05. RESULTS : Seventy-one patient records met the selection criteria with the majority being females (70%). The age range was between 10 and 37 with a mean of 17.5 years. Thirty-five patients were treated with extractions and thirty-six patients with non-extraction treatment. There was a significant difference in the visible maxillary dentition pre and post treatment with extraction patients showing a 6 to 6 and non-extraction showing 5 to 5 dentition post treatment (p<0.05). There were no differences in the ratios of the visible maxillary dentition and oral aperture in both groups pre and post treatment (p> 0.05 CONCLUSION : Orthodontic treatment of Class 1 cases with premolar extraction did not lead to deleterious changes in the buccal corridors.
Oral hygiene habits and status of orthodontic patients attending the University of Pretoria, Oral and Dental Hospital
(South African Dental Association, 2021-04) Buthelezi, Noluthando Loveness; Madiba, Thomas Khomotjo
BACKGROUND : Most orthodontic patients struggle to maintain good oral hygiene during treatment. AIM : To determine oral hygiene habits and status of patients undergoing fixed orthodontic treatment at University of Pretoria, Oral and Dental Hospital. DESIGN : A cross-sectional descriptive study. MATERIAL AND METHODS : A modified, validated, self-administered questionnaire was used, and clinical examinations were conducted using Orthodontic Plaque Index, Gingival index, and Bleeding index. The questionnaire sought to determine knowledge and practice patterns. Data analysis included frequencies and correlations using chi-square test, with a significance of p<0.05. RESULTS : Fifty patients participated with 34(68%) being female with ages from 10 to 28 and a mean of 18,5. Seventy percent avoided sticky foodstuff, 74% used mouthwash, 56% flossed daily and 84% brushed twice daily. However, 82% consumed sugar containing drinks Clinical exam revealed an Orthodontic Plaque Index mean of 2.6, Gingival Index mean of 0.1 while the Bleeding Index was 13.3 and 90% had normal gingiva. There was a significant difference in Gingival Index score between patients at age category 10-19 and 18-24 (p< 0.05). CONCLUSIONS : This study revealed a satisfactory oral hygiene status among patients at the institution with the majority of patients maintaining good oral hygiene practices. However, 82% consumed sugar sweetened beverages
The epidemiology of malocclusion in Zambian urban school children
(South African Dental Association, 1998-08) Ghabrial, Emad; Wiltshire, William; Zietsman, Seugnet; Viljoen, Ella
This survey was undertaken to determine the occlusal status of a selected group of urban Zambian Black 9-12 year old children at 5 different schools in the same geographical area in order to determine their need for orthodontic treatment. The examination criteria of the Occlusal Index of Summers (1966) were used. Six hundred and one children who had not previously received orthodontic treatment were examined. The data were analysed statistically by using the calculated Summers Index. The results showed that 83 per cent of the subjects required no orthodontic treatment. Of the 17 per cent who did require orthodontic treatment, 5.2 per cent needed specialized treatment. The malocclusion status of Black Zambian children is very similar to that recorded in epidemiological studies on South African and Swazi Black children. This study indicates that only a small need exists for orthodontic treatment amongst Black Zambian children.
The orthodontist's views regarding academic education in cleft lip and palate as well as craniofacial deformities in South Africa
(South African Dental Association, 2021-05) Ghabrial, Emad; Butow, Kurt-Wilhelm; emad.ghabrial@up.ac.za
BACKGROUND : Orthodontists are essential members of a craniofacial team (American Cleft Palate-Craniofacial Association Team Standards Committee)1. Because cleft lip/palate (CLP) and craniofacial deformities (CFD) vary in severity and facial growth patterns, treatment is complex and lengthy and requires collaboration among different disciplines. Consequently, orthodontists need specialised training in this field to reach the treatment goals of good facial growth, aesthetically acceptable appearance, and dental occlusion. Therefore, it becomes increasingly important to provide adequate training for orthodontists, so they can not only provide efficient treatment but can also undertake a leadership role in the field. OBJECTIVES : To obtain information regarding: the CLP and CFD academic education of orthodontists the professional services that orthodontists offer to CLP and CFD patients the educational and training needs of orthodontists in this field METHOD : A 54-item online survey to collect quantitative data was conducted by means of an interview, using a randomised sample of orthodontists attending the annual scientific conference of the South African Society of Orthodontics. RESULTS : The questionnaire was completed by 53 orthodontists, 54.6% of whom had more than 10 years of professional experience. Of the respondents, 84.8% experienced some clinical exposure in this field during their postgraduate education. Treatment for CLP and CFD patients was offered by 92% of the professionals, but only 21.7% had high confidence in their expertise in treating CLP/CFD patients. Of the respondents, 88% agreed there was a need to improve CLP and CFD education, and the majority recommended fellowship training and certified courses. The rest suggested continuing-education workshops. CONCLUSION : Most of the orthodontists provided treatment for both CLP and CFD patients despite some of them lacking confidence in treating such cases. The majority agreed that there is a strong need to establish an educational strategy to meet the needs of orthodontists who treat CLP and CFD patients. The respondents suggested that programmes such as fellowship training, degree couses, certified courses, and continuing education workshops could be used.
Primary surgery effect on dental arch relationships of patients born with unilateral cleft lip and palate using the GOSLON yardstick index
(South African Dental Association, 2021-06) Ghabrial, Emad; Van den Berg, Hester J.S.; Du Plessis, Susanna M.; emad.ghabrial@up.ac.za
OBJECTIVES : To score dental arch development using the Great Ormond Street, London, and Oslo (GOSLON) yardstick index, following primary surgery in patients with a complete unilateral cleft lip and palate (UCLP), and to compare the outcome score with the GOSLON score of Cleft Care UK (CCUK) as well as with the Clinical Standards Advisory Group (CSAG), United Kingdom. METHODS : Study models of patients (average age 12 years) with a non-syndromic complete UCLP, who had been surgically treated at the University of Pretoria Facial Cleft Deformity (UPFCD) clinic. They were assessed using the GOSLON yardstick index by certified raters from the Dental School in Dundee, Scotland. The mean outcome ratings were calculated from the scoring of 27 sets of plaster models. The other scoring rounds were used to calculate intra- and inter-observer agreement using Cohen's weighted kappa and Fleiss's multi-rater kappa. RESULTS : There were strong intra- and inter-observer agreement, with a weighted kappa of 0.92. The Facial Cleft Deformity (FCD) clinic data showed a good treatment outcome with a mean GOSLON rating of 2.85 compared to a rating of 3.2 for the CSAG and 2.62 for the CCUK cohort studies. CONCLUSION : The UPFCD clinic primary surgical protocol displayed a good treatment outcome rating, in line with that of the CCUK cohort and better than the CSAG results.
A survey of South African maxillofacial & oral surgeon opinions regarding the academic education in the field of cleft lip/palate and craniofacial deformities
(South African Dental Association, 2020-06) Ghabrial, Emad; Butow, Kurt-Wilhelm; emad.ghabrial@up.ac.za
South African speech-language therapists’ opinion of their training in cleft lip and palate and craniofacial deformities
(AOSIS OpenJournals, 2020-07-30) Ghabrial, Emad; Butow, Kurt-Wilhelm; Olorunju, Steve A.S.; emad.ghabrial@up.ac.za
BACKGROUND : Speech care of cleft lip and/or palate (CLP) and craniofacial deformities (CFD) is complex and lengthy and requires collaboration amongst different disciplines. Consequently, it is important to provide academic educational models that include didactics, online learning and clinical exposure in CLP and CFD treatment, and participation in established cleft palate multidisciplinary team management. OBJECTIVES : To obtain information regarding: (1) the perceived adequacy of CLP and CFD academic education of speech-language therapists (SLTs); (2) the professional services that SLTs offer to CLP and CFD patients; and (3) the educational needs of SLTs in this field. METHOD : A 54-item online survey to collect quantitative data was conducted by telephone and email using a randomised sample of SLTs in different areas of South Africa. RESULTS : The questionnaire was completed by 123 SLTs, 70% of whom had more than 10 years of professional experience. Of the respondents, 81% acknowledged their limited clinical exposure during their academic education. Only 42% of the professionals offer treatment for CLP and CFD patients. Of the respondents, 96% agreed on the need to improve CLP and CFD academic education, and the majority recommended certified courses, continued-education workshops and online resources. CONCLUSION : The findings indicate that SLTs academic training is perceived to be significantly limited in the cleft palate and craniofacial fields. Thus, there is a strong need at the undergraduate level for clinical training and exposure to multidisciplinary management. At post-graduate level there is a need to establish an educational strategy to meet the needs of SLTs providing CLP and CFD care. Participants suggested that programmes for continuing professional education, degree courses and online resources be designed to provide practising clinicians with updated information and guidance in management of CLP and CFD patients.
Treatment of thumb-sucking habit using a fixed tongue crib appliance - a case report and literature review
(South African Dental Association, 2019-06) Reddy, D.; Dawjee, Salahuddien M.; s.dawjee@up.ac.za
A prolonged thumb sucking habit is associated with certain dental malocclusions. Numerous techniques and appliances have been reported for the treatment of thumb sucking, all having varying degrees of success. This report presents a clinical case of a seven year old female patient with thumb sucking habit and an anterior open bite. Through careful motivation, good patient compliance and a fixed tongue crib, the habit ceased and there was spontaneous correction of the anterior open bite within a treatment period of six months.
Introducing the alveolar moulding obturator (AMO) : an appliance for the early management of cleft palate neonates
(South African Dental Association, 2019-04) Dawjee, Salahuddien M.; Dawjee, M.M.; s.dawjee@up.ac.za
Clefting of the lip and palate is one of the most common congenital malformations encountered worldwide. It affects about 1 to 1.6 per 1000 live births and is more common in males than in female, occurring more frequently on the left side than it does on the right side of the face. The condition can come as a severe emotional shock to parents, particularly in third world countries where prenatal detection is not affordable and parents cannot be sensitised before the birth of their child. Such emotional trauma can lead to a sense of blame, guilt and strained social relations at a time when family support is most needed.
The mandibular anterior repositioning appliance (MARA) - a report of three cases
(South African Dental Association, 2019-11) Weber, J.H.; Botha, Piet; Dawjee, Salahuddien M.
INTRODUCTION : The MARA (Mandibular Anterior Repositioning Appliance) is a fixed functional appliance used in the treatment of mandibular deficiencies. AIMS AND OBJECTIVES : To demonstrate the clinical capabilities, treatment effects and the expected duration of treatment when using the MARA, therefore creating awareness of the MARA as a treatment alternative to other functional appliances designed for correction of Class II malocclusions. METHODS : A retrospective study exploring the anteroposterior dimensional changes in the maxilla and mandible brought about by the MARA and the associated treatment time. The samples were the first three cases treated by a clinician inexperienced with the clinical application of the MARA and served as an ideal introduction to the treatment technique. RESULTS : In this study mandibular growth stimulation and temporomandibular joint remodeling may have been the main contributing factors in the resolution/improvement of the Class II malocclusions under treatment. CONCLUSION : The MARA is a useful non-compliance appliance that produces exceptional treatment results when applied in combination with full fixed appliances. The changes observed were predominantly of a skeletal nature in the anteroposterior dimension. Maxillary growth restriction may also have played a role in the correction of these treated Class II abnormalities.
Enamel demineralisation as an iatrogenic effect of orthodontic treatment : a clinical review
(South African Dental Association, 2018) Omar, Shazia; Dawjee, Salahuddien M.
Small areas of demineralised enamel, commonly referred to as white spot lesions (WSLs), constitute an important clinical problem in Orthodontics following treatment with fixed appliances. They are the result of an imbalance between de- and remineralisation of enamel, caused by the interrelationship of several factors. Clinicians and patients are usually so focussed on the alignment of teeth within the arches and the relationship of the jaws to each other, that the iatrogenic effects of demineralisation and WSLs are often overlooked. While attempts should be, and are, made to prevent this clinical problem, it can pose a challenge to manage in high risk patients. Benefit must supersede risk and it is thus of utmost importance that the clinician be aware of and educates the patient on means to prevent or to minimise and manage WSLs. This manuscript is intended to elucidate the presentation, aetiology and management of WSLs, in the hope of promoting more favourable clinical outcomes for both patient and practitioner.
The orthopantomograph as an indicator of vertical jaw relations
(South African Dental Association, 2018-11) Suliman, Mohamed F.; Dawjee, Salahuddien M.; s.dawjee@up.ac.za
INTRODUCTION : Lateral cephalometry is important in the orthodontic diagnosis of jaw relationships, in treatment planning, and prediction of growth but also in the evaluation of different facial forms. Little research has evaluated the orthopantomograph for these purposes. AIM : To compare the data taken from orthopantomographs and lateral cephalograms in the investigation of vertical jaw relationships and to assess correlation between measurements. MATERIALS AND METHODS : The gonial angle, ramus height and condyle angle were measured for each patient on the two radiographs and these data compared for the three different facial growth types, dolichofacial, mesofacial and brachyfacial. RESULTS : In subjects with normal (meso-) or horizontal (brachy-) growth patterns, there were no significant differences between the mean and median values for the gonial and condyle angles, but the ramus heights showed significant differences. The data of the vertical (dolicho-) growth pattern patients recorded significant differences only between the data for the gonial angles and the ramus heights. Significant correlations were found between the gonial angles and the condyle angles for all three growth patterns, but not for ramus heights. CONCLUSION : in comparing the data from the two radiographs, the angular measurements showed high correlation and predictability whilst linear measurements showed inconsistency.
Part 15 : Secondary use of unethically obtained data : fifty shades of grey/ aye/nay
(South African Dental Association, 2017-11) Sykes, Leanne M.; Evans, William G.; Gani, Fatima; Vally, Zunaid Ismail; Dullabh, Hemant D.; leanne.sykes@up.ac.za
On a regular basis, dental practitioners have to make decisions regarding their care of their patients. Previously, dentists did this almost instinctively, drawing upon personal resources such as clinical experience, training, colleagues’ opinions, social media and past successes…and failures. Today it is expected that good clinical practice be based on the best and most currently available evidence, obtained by critical appraisal of scientific research and literature, books, journals, internet publications, and participation at continuous education programmes. This has led to an explosion in research, not all of which is scientifically sound or ethically acceptable. Evidence based dentistry (EBD) evolved as a means of evaluating the science and rigour of research (the focus of the next chapter in this series), while numerous codes of conduct have been developed to try to ensure ethical standards.
Keratocystic odontogenic tumour masquerading as a mucosal antral cyst
(South African Dental Association, 2015-06) Carim, R.; Mahomed, F.; Ngwenya, S.; Rokhotso, E.
Keratocystic odontogenic tumour (KCOT) is of clinical importance because of its pronounced tendency to recur. Among the factors that complicate KCOT management are its protean radiological presentations. KCOT showing involvement of the maxillary antrum in the absence of an associated impacted tooth is exceptionally rare. In these instances an odontogenic source of the lesion is often not suspected and the clinico-radiological features may be misinterpreted. We report such a case and highlight pertinent clinical and radiological features of antral KCOT.
Lip tape therapy in patients with a cleft lip – a report on eight cases
(South African Dental Association, 2014-03) Dawjee, Salahuddien M.; Julyan, J.C.; Krunauw, J.C.; s.dawjee@up.ac.za
INTRODUCTION: Lip tape therapy or lip taping is a widely used tissue approximation technique in cleft lip babies. Various tapes have been tested and used worldwide. Allergic reactions and skin irritation are the most common problems encountered. Tension force across the tape cannot be consistently applied. Cost is also an obstacle to adopting lip tape therapy, particularly in developing countries. AIM: A study was undertaken to evaluate a different tape, “physio tape”, which has never been used for lip approximation in cleft lip babies. METHOD: Eight babies were available for this study, which was conducted over a six-week period (Ethical Approval number 33/2013). Standardised pre- and post-treatment recordings were made with a digital camera and soft tissue analysis was carried out with Cliniview software. RESULTS: All participants showed a reduction in cleft size ranging from 9.1mm to 36.7mm at the vermillion end of the cleft. Caregivers had no difficulty with the lip tape procedure and generally no untoward or allergic reactions were reported. CONCLUSION: On the basis of the positive results of this investigation, it is recommended that this method of lip tape therapy be used on all babies born with a cleft lip. It is affordable, simple to use and should facilitate the surgical repair.
Compliance and satisfaction in the orthodontic patient
(South African Dental Association, 2012-09) Nel, W.R.; Dawjee, Salahuddien M.
It behoves an orthodontist to regard patients seeking treatment for malocclusion as valued customers who should remain satisfied clients. However, without patient cooperation, few medical or dental therapies, including orthodontics, will achieve optimum results. It has been shown that a desire for orthodontic treatment, together with a sound understanding by the patient of the nature of the malocclusion, auger well for future compliance. Hence, compliance does not remain the sole responsibility of the patient. Rather, orthodontists need to inform and instruct their patients to such a level as to ensure their full commitment. It is of concern that patients show a very low recall rate with regard to any risks associated with orthodontic treatment. Lack of communication between the orthodontist and the patient and insufficient information about orthodontics can lead to premature termination of the treatment. Orthodontists should therefore look at the way they educate patients, ensuring that full comprehension has been achieved. Measuring treatment satisfaction is a complex task. Patient satisfaction is higher when visible treatment outcome goals are met and when their expectancy with regard to psychosocial benefits is lower. The key to success is to discover the actions that will produce the most positive response from the patient. Orthodontists should strive to achieve the correct bite and an excellent smile, but they have not been truly successful if their patients have not also benefitted psychosocially. Orthodontists should recognise and respond to these needs, for as caring professionals they may be the patient's only source of positive reinforcement.

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