title: A review of the evidence supporting the aesthetic orthodontic treatment need indices.
abstract: OBJECTIVE
  Aesthetic improvement and psychological enhancement have been cited as justifications for orthodontic treatment. This paper reviews the evidence that relates malocclusion to psychological health and quality of life and explores whether this evidence supports the most commonly used aesthetic Orthodontic Treatment Need Indices (OTNI).
  
  
  METHODS
  The relevant cited material from the MEDLINE, Web of Science, Scopus, Cochrane databases, and scientific textbooks were used. The citation rate was confirmed by using the Google Scholar.
  
  
  RESULTS
  The subjective nature of aesthetic indices and the variable perception of attractiveness between clinicians and patients, and among various cultures or countries are a few limitations of aesthetic OTNI. The available evidence of mainly cross-sectional studies on the link between malocclusion and either psychosocial well-being or quality of life is not conclusive, and sometimes contradictory, to suggest these characteristics are affected by malocclusions. Further, the long-term longitudinal studies did not suggest that people with malocclusion are disadvantaged psychologically, or their quality of life would be worse off, which challenges using aesthetic OTNI to assess the social and psychological implications of malocclusion.
  
  
  CONCLUSIONS
  The subjective nature of aesthetic OTNI and the minor contributory role of malocclusion in psychosocial health or quality of life undermine using aesthetic indices to assess the likely social and psychological implications of malocclusion. Consequently, using aesthetic OTNI, as a method to quantify malocclusion remains open to debate. Various soft and hard-tissue analyses are used before formulating a treatment plan (i.e., assessment of sagittal and vertical skeletal relationships). The addition of a shortened version of these analyses to the aesthetic OTNI can be a good substitute for the aesthetic components of OTNI, if an assessment of the aesthetic aspects of malocclusion is intended. This reduces subjectivity and improves the validity of the OTNI that incorporate an aesthetic component.
authors.affiliation: University of Warwick, Warwick Dentistry, Warwick Medical School, Coventry, UK. farahani@faraortho.com
authors.forename: Ali
authors.initials: A
authors.lastname: Borzabadi-Farahani
mesh_terms: D004955:Esthetics, Dental; D055094:Evidence-Based Dentistry; D006801:Humans; D061326:Index of Orthodontic Treatment Need; D008310:Malocclusion / Q000523:psychology; D011788:Quality of Life; D012649:Self Concept