Effects of Visual Stimuli from Media on the Perception of Dentofacial Esthetics

Abstract

Objectives

The study explored whether television commercials change the perception of one's own dentofacial attractiveness and to identify if it is influenced by personality traits.

Materials and methods

The sample included 83 participants, aged 19-27 years. The experimental group (N=42) watched commercials portraying famous young individuals with high smile esthetics, bright teeth and no visible malocclusions, while the control group (N=41) watched neutral commercials (without people or visible teeth). The perception of subjects` own orofacial esthetics and its psychosocial effects were assessed a month before the exposure and immediately after it. The subjects` malocclusion severity and personality characteristics (extraversion, conscientiousness, agreeableness, neuroticism, intellect, self-esteem and perfectionism) were assessed.

Results

In their second report, respondents were inclined to report less psychosocial impacts with small differences (ranging from 0-3 scalar points on average) and less significant in the active group compared to neutral group (2 out of 7 vs. 5 out of 7 aspects). Types of visual stimuli were a significant predictor only of changes pertaining to psychological impact of dental esthetics (p=0.045; r=0.221). The intellect moderated perception of smile esthetics, after having been exposed to commercials, accentuated beautiful smiles as a suppressor (ΔR²=0.076; p=0.005; total model R²=0.347; p=0.033). In subjects with higher cognitive abilities, an increase in the self-perceived malocclusion level induced a smaller decrease in psychological impact of dental esthetics as compared to those with lower intellect.

Conclusion

Psychosocial influences of malocclusion are not stable and tend to decrease during time. However, the exposure to a high smile esthetic of other individuals can inhibit that process in persons with more severe malocclusion and higher cognitive abilities.

Introduction

Media play significant roles in information dissemination and idealized images on how to obtain a perfect external appearance (1, 2). Marketing commercials are designed to provoke emotions often by using smile with visible teeth, which is associated with joy and pleasant social interactions (3, 4). Therefore, the content of visual stimuli, through media, is partly responsible for self-appraisal (5-7). A television commercial is a form of advertising, usually a short form of 30 seconds in duration, which conveys a message promoting, and aiming to market, a product or service. Even a short period of watching television programs and commercials can alter the cognition of appearance in women and majority would like to obtain this ideal beauty that is portrayed on television (1, 8).

Media stereotypes provided by images of superior beauty play a central role in creating and deteriorating body dissatisfaction. Furthermore, media stereotypes create and maintain a relation between the ideal of having a slim body and positive attributes such as sense of control, success and attractiveness (9). Dissatisfaction and shame is created when comparisons are made between the media ideals and people`s own ideals (9). Accordingly, it has been proven that ideal images in media are associated with low self-esteem, lower satisfaction with physical appearance, and depressive behavior in females (2).

The face is considered to be a more important factor for overall attractiveness than the body, thus influencing one's self-esteem, social adjustment and integration (10). Patients wishing to undergo orthognathic surgery often express dissatisfaction with one or more aspects of their face implying that esthetic concern is probably the most prominent motive for surgery (11).

The aim of the study was to investigate to what extent media influence the perception of dentofacial esthetics. In other words, the aim was to investigate into how commercials that promote products that use the smile and teeth in the context of a positive and desirable outcome, are changing the satisfaction with their teeth, smile appearance, and social and emotional effects of smile attractiveness. In addition, the aim was to explore whether this relationship is influenced by an objective clinical condition and whether this process is influenced by personality traits and gender.

It was hypothesized that a decrease in satisfaction with one's own dentofacial appearance, and an increase in psychosocial impacts after the exposure to positive visual stimuli, is probably higher in females with higher self-perceived malocclusion severity, perfectionism, neuroticism, and lower self-esteem.

Materials and methods

Our research design was experimental with two parallel groups. At first, it was supposed to include 90 subjects, first to fifth year dental students from the University of Rijeka in the age range of 19-27 years. The inclusion criteria were: having natural teeth from first molar to first molar in both jaws. The exclusion criteria were: orthodontic treatment, anterior restorations and syndromes. The research was undertaken with the understanding and written consent of each participant and in full accordance with ethical principles. Approval for this study was given by the Ethics Committee of the Faculty of Medicine Rijeka (2170-24-01-15-05). The subjects were randomly assigned to two groups of 45 respondents using the function “random between” in the Microsoft Excel software. The estimation of the sample size was based on previous research (12). Paired difference of means of Psychosocial Impact of Dental Aesthetics Questionnaire (PIDAQ) dimensions in a repeated administration of instrument without any dental treatment (test-retest reliability) ranged 0.19-0.71 (mean 0.4). Supposing that the difference between neutral and experimental group would be 0.4 (neutral group would have difference of means between two administration of 0.4, while experimental double of that amount), hypothetical standard deviation in both groups of 0.6 and ratio of sample sizes in group 1 / group 2=1, power ß=0.8 and probability level α=0.05, and 36 subjects in each group were the minimal sample size. By adding a dropout rate of 20%, a total number of 86 was reached. Therefore, 90 subjects were initially recruited. The calculation of the minimum required sample size was made by the use of the commercial statistical software MedCalc 14.8.1 (MedCalc Software BVBA, Ostend, Belgium). Due to incomplete questionnaires or giving up from the trial, seven subjects were excluded. Ultimately, the data from 83 subjects (61% females) aged 19-27 years (median 21, range 20-22) were analyzed - 42 in the experimental (24 females) and 41 in the control group (27 females). Each subject was unaccompanied when watching a clip with five consecutive television commercials for a period of 1:45 minutes in a classroom. On the one hand, the experimental group watched commercials at one seating with positive visual stimuli (a body image stressor) which were showing both young men and women that are well known, successful, healthy, and happy. Furthermore, they had beautiful smiles, bright teeth and no visible malocclusions, accentuated in first plan, which advertised body and face creams, exercise equipment and lipsticks. On the other hand, the control group watched commercials with neutral visual stimuli that were advertising dog food, cars, fuel manufacturers, and sanitary napkins. Within the controlled group, only one commercial presented people, however, frowning and with no visible signs of teeth. A month before the exposure to visual stimuli and immediately after the exposure the respondents filled in the questionnaires which assessed the perception of their own orofacial esthetics and its psychosocial effects. One month was considered to be sufficient time for respondents to think over all aspects and roles in social interactions prior to exposure. Validated Croatian versions of psychometric instruments were used: Oral Health Impact Profile (OHIP), Orofacial Esthetic Scale (OES) and PIDAQ (12-14). PIDAQ contains 23 statements for assessing specific aspects of dental esthetics-related quality of life, grouped into four dimensions: Dental Self-Confidence (DSC; 6 items; range 0=low/not at all-24=high/very much), Social Impact (SI; 8 items; range 0=low-24=high) Psychological Impact (PI; 6 items; range 0=low-32=high) and Aesthetic Concern (AC; 3 items; range 0=low-12=high) (12). OES is a one-dimensional instrument composed of 8 items for measuring satisfaction with defined elements of orofacial esthetics through Likert scale (range 8=completely dissatisfied – 40=completely satisfied) (14). OHIP is a multidimensional questionnaire that assesses oral health-related quality of life. In this study, two of four dimensions were used: Orofacial Aesthetics (OFA; 6 items; range 0=never at all-24=very frequently) and Psychosocial Impact (PSI; 15 items; range 0=never at all-60=very frequently) (13, 15).

Personality traits were expected to be stable, hence they were estimated once, a month before the exposure with the validated Croatian version of psychometric instruments Big Five Inventory (BFI), Rosenberg Self-esteem Scale (RSS) and Multidimensional Perfectionism Scale – Frost (MPS-F) (16-18). They included extraversion (8=low-40=high), agreeableness (9=low-45=high), conscientiousness (9=low-45=high), neuroticism (8=low-40=high), openness (10=low-50=high), self-esteem (10=low-50=high) and perfectionism in dimensions Concern over mistakes (9=low-45=high), Organization (6=low-30=high), Parental expectations (5=low-25=high), Personal standards (7=low-35=high), Doubts and actions (4=low-20=high), Parental criticism (4=low-20=high) and Global perfectionism (without organization) (29=low; 145=high).

Smile esthetics and occlusion were clinically evaluated by two examiners (AP and SS) one month before the exposure by the Index of Orthodontic Treatment Need - Dental Health Component (IOTN DHC; 1=no/minor malocclusion - 5=definite malocclusion) and Aesthetic Component (IOTN AC; range 1=best – 10=least esthetic) and the Index of Complexity, Outcome and Need (ICON; range 7=no/minor malocclusion-120=major malocclusion) (19, 20). Inter- and intra-examiner reliability were assessed in 30 subjects (for inter-examiner test-retest in one-week interval). Weighted Cohen Kappa for IOTN DHC and Intraclass Correlation Coefficient for IOTN AC and ICON were used. Intra-examiner agreement ranged from 0.838-0.947, indicating good or very good reliability. Inter-examiner agreement was somewhat lower, but still good, ranging from 0.673 to 0.758. Inter- and intra-examiner reliability were higher for ICON, and somewhat lower for IOTN DHC and AC. Two sliding calipers the accuracy of which was 0.05 and 0.55 mm and precision 0.69 and 0.89 mm were used. The subjects reported their self-perception of smile attractiveness through IOTN AC. They reported satisfaction with teeth and facial appearance and a self-perceived need for treatment on teeth, smile and face with statements on a five level Likert scale (0=not at all - 4=very much). They reported body image, i.e. importance of teeth appearance for appearance of the body with statements on a five level Likert scale as well. The statistical analysis used the t-test for dependent and independent samples, Pearson correlation and linear regression analysis in commercial software IBM SPSS 22 (IBM Corp., Armonk, NY, USA) and MedCalc 11.2. (MedCalc Software, Mariakerke, Belgium). Statistical significance was set to p<0.05. The effect size was calculated by the formula r=√t2/(t2+df), and in the interpretation the Cohen's criteria were used: r=0.1-0.3 = small effect size, 0.3-0.5 = medium and >0.5 = large.

Results

Characteristics of the sample are presented in tables 1 and 2. There were no major differences in age and gender, and, also, in most of the tested clinical and psychosocial dimensions between the active and experimental group. The subjects in the control group reported slightly higher degree of self-perceived malocclusion at the start (2.2±1.2 vs. 1.7±0.8; p=0.026) and lower DSC (14.8±4.9 vs. 16.9±4.2; p=0.039), however, with small effect sizes (r = 0.248 and 0.237).

Table 1. Clinically estimated degree of malocclusion and subject opinions concerning orofacial esthetics.

Variable (range)	median	IQR	min	max
IOTN DHC (1=no/minor malocclusion - 5=definite malocclusion)	2	2-3	1	4
Importance of teeth appearance for body image (0=not at all - 4=very much)	4	3-4	1	4
Teeth appearance satisfaction(0=not at all - 4=very much)	3	2-3	0	4
Face appearance satisfaction (0=not at all - 4=very much)	3	2-3	2	4
Self -perceived need for teeth and smile treatment (0=not at all - 4=very much)	1	0-2	0	4
Self-perceived need for face treatment (0=not at all - 4=very much)	0	0-1	0	3

IQR – interquartile range

Table 2. Malocclusion severity and psychosocial profile.

Variable (range)	mean	std. deviation	min-max
IOTN AC self-assessed (1=best–10=least esthetic)	2.0	1.0	1-5
IOTN AC professionally assessed (1=best–10=least esthetic)	2.1	1.1	1-7
ICON score (7=no/minor malocclusion-120=major malocclusion)	20.4	12.0	7-57
Self-esteem (10=low-50=high)	43.1	4.5	32-50
Extraversion (8=low-40=high)	29.4	4.7	17-38
Agreeableness (9=low-45=high),	33.6	4.6	20-45
Conscientiousness (9=low-45=high)	34.8	4.6	25-45
Neuroticism (8=low-40=high)	19.6	5.1	11-33
Intellect (10=low-50=high)	37.8	4.9	27-48
Concern over mistakes (9=low-45=high)	19.1	6.8	9-44
Organization (6=low-30=high)	25.3	3.7	14-30
Parental expectations (5=low-25=high)	11.3	4.2	5-23
Personal standards (7=low-35=high)	23.1	4.5	12-34
Doubts and actions (4=low-20=high)	9.5	3.3	4-18
Parental criticism (4=low-20=high)	6.1	2.5	4-14
Global perfectionism (without organisation) (29=low; 145=high)	69.0	14.4	36-118
Satisfaction with orofacial esthetics, OES (8=completely dissatisfied – 40=completely satisfied)	32.6	3.9	23-40
Orofacial aesthetics, OHIP OFA (0=never at all-24=very frequently)	7.0	4.2	0-20
Psychosocial impact, OHIP PSI (0=never at all-60=very frequently)	3.4	5.3	0-21
Aesthetic concern, AC (0=low-12=high)	2.0	2.2	0-9
Psychological impact, PI (0=low-32=high)	5.6	3.8	0-17
Social impact, SI (0=low-24=high)	3.1	3.9	0-18
Dental self-confidence, DSC (0=low-24=high)	15.8	4.6	2-24

Female gender was related to more frequent psychosocial influences measured by OHIP (p=0.012). Self-reported satisfaction with smile and face appearance and the need for treatment were related to psychosocial impacts of dental esthetics, more with PIDAQ dimensions than OHIP (Table 3). Satisfaction with orofacial esthetics and psychosocial impacts of dental esthetics did not depend on the body image, and they were poorly related to personality traits (Table 3). Self-esteem correlated with all used instruments of quality of life, the most being DSC and AC (Table 3). Perfectionism was an important determinant of psychosocial impact of dental esthetics and orofacial appearance, mostly due to dimension Concern over mistakes (Table 3).

Table 3. Correlations of quality of life related to dentofacial esthetics with psychological traits before the stimulus (N=83).

Variable		OES	OHIP OFA	OHIP PSI	AC	PI	SI	DSC
ICON score	r	-0.187	0.254	0.168	0.236	0.158	0.081	-0.362
	p	0.090	0.020	0.128	0.032	0.155	0.468	0.001
IOTN AC	r	-0.215	0.116	0.157	0.293	0.364	0.160	-0.473
Examinee	p	0.051	0.296	0.157	0.007	0.001	0.147	<0.001
Body image	r	0.009	0.027	-0.030	-0.099	-0.091	-0.120	0.104
	p	0.939	0.810	0.787	0.374	0.414	0.282	0.349
Satisfaction with teeth appearance	r	0.569	-0.198	-0.256	-0.397	-0.659	-0.234	0.710
p	<0.001	0.073	0.020	<0.001	<0.001	0.008	<0.001
Satisfaction with face appearance	r	0.475	-0.051	-0.157	-0.318	-0.450	-0.299	0.502
p	<0.001	0.652	0.160	0.004	<0.001	0.006	<0.001
Self-assessed treatment need smile	r	-0.403	0.288	0.408	0.487	0.593	0.216	-0.586
p	<0.001	0.009	<0.001	<0.001	<0.001	0.051	<0.001
Self-assessed treatment need face	r	-0.373	0.172	0.215	0.321	0.344	0.259	-0.258
p	0.001	0.123	0.052	0.003	0.002	0.019	0.019
Self-esteem	r	0.283	-0.310	-0.241	-0.420	-0.344	-0.394	0.458
	p	0.010	0.004	0.028	<0.001	0.001	<0.001	<0.001
Extraversion	r	0.259	-0.114	-0.100	-0.078	-0.223	-0.154	0.210
	p	0.018	0.306	0.367	0.485	0.043	0.164	0.057
Agreeableness	r	0.237	0.039	0.051	-0.139	-0.160	-0.205	0.120
	p	0.031	0.726	0.644	0.210	0.147	0.063	0.278
Conscientiousness	r	0.305	-0.125	0.017	-0.107	-0.203	-0.207	0.109
	p	0.005	0.258	0.882	0.336	0.065	0.061	0.325
Neuroticism	r	-0.272	0.216	0.194	0.221	0.203	0.253	-0.173
	p	0.013	0.050	0.078	0.044	0.065	0.021	0.119
Intellect	r	0.026	0.020	0.078	0.077	0.040	0.061	-0.064
	p	0.815	0.858	0.485	0.490	0.717	0.582	0.563
Concern over mistakes	r	-0.219	0.361	0.403	0.217	0.323	0.352	-0.174
p	0.047	0.001	<0.001	0.048	0.003	0.001	0.116
Organization	r	0.263	0.049	0.144	-0.050	-0.204	-0.138	0.135
	p	0.016	0.657	0.193	0.655	0.064	0.213	0.223
Parental expectations	r	-0.032	0.107	0.265	-0.018	-0.109	0.001	0.185
p	0.776	0.334	0.015	0.871	0.328	0.993	0.095
Personal standards	r	0.053	0.123	0.192	0.075	-0.071	-0.058	0.061
p	0.635	0.27	0.082	0.498	0.522	0.604	0.585
Doubts and actions	r	-0.230	0.233	0.279	0.242	0.267	0.174	-0.191
p	0.037	0.034	0.011	0.027	0.015	0.117	0.084
Parental criticism	r	-0.110	0.211	0.246	-0.040	-0.044	0.015	0.141
	p	0.321	0.055	0.025	0.717	0.696	0.893	0.202
Global perfectionism	r	-0.167	0.330	0.434	0.169	0.152	0.191	-0.029
p	0.133	0.002	<0.001	0.126	0.170	0.084	0.797

r-correlation coefficient, p-significance level.

In their second report, after the exposure to commercials, the respondents tended to report a smaller amount of psychosocial impacts, regardless of gender (Figure 1). The differences were small (ranging from 0-3 scalar points on average) and less often significant in active than neutral group (2 out of 7 vs. 5 out of 7 aspects). Reduction of the psychological impact in neutral commercials was more pronounced than in smile commercials group with small effect size (p=0.045; r=0.221). The amount of changes had only few correlations with psychological characteristics, malocclusion severity, self-perceived treatment need, and the correlations were poor to moderate (r≤0.433).

Figure 1.

Comparison between perceptions of quality of life related to dentofacial esthetics between the two groups before and after the exposure to visual stimuli

Stepwise regression analysis was used to explore whether personality traits in the active group incurred a change of psychological impact of dental esthetics (Δ=T1-T0), the only dimension that significantly differed between the active group and the placebo group. Self-perceived malocclusion severity (IOTN AC), treatment need and satisfaction with teeth and face appearance were used as a measure of pre-experimental smile esthetics. A moderation effect has been proven only for intellect i.e. openness to experience that acted as a suppressor (ΔR²=0.076; p=0.005; total model R²=0.347; p=0.033). In subjects with higher intellect, increasing the self-perceived malocclusion level induced a smaller decrease in psychological impact of dental esthetics compared with those of lower intellect (Figure 2).

Figure 2.

Moderation effect of intellect on the relationship between self-perceived severity of malocclusion and change of psychological impact of dental esthetics

Discussion

This study confirmed the fact that satisfaction with persons' own esthetics is more related to their own perception of the condition than their actual clinical condition. Psychosocial influences of malocclusion are not stable and media can, depending on the personality, affect the perception of their own orofacial esthetics.

Contrary to what was expected, not all psychosocial impacts were related to higher clinically assessed malocclusion severity; it is mainly dental self-confidence. Psychosocial impacts were more induced by self-perceived treatment need and satisfaction with teeth appearance. Many factors apart from malocclusion (such as discoloration, abrasion, caries, gingivitis, tooth fracture or tooth loss) cause psychosocial effects, and psychosocial effects regulate the motivation of individuals to make decisions to seek and to undergo treatment (21-24, 25). The present research also implies that women are more critical in the evaluation and they report psychosocial influences more often than men. This is in line with previous research that linked female gender with two times higher chance of dissatisfaction with their own appearance, despite the fact that dental esthetics is equally important to younger and elderly people (25).

It was expected that lower psychosocial impacts of smile esthetics are associated with higher self-esteem and extraversion, and lower neuroticism and perfectionism. According to current research, self-esteem is a characteristic which is mostly related to psychosocial influences, implying that one’s overall sense of his or her value improve social interactions and empower positive emotions (17). The most significant relation is with dental self-confidence, which refers to trust in oneself and ability to deal with challenges. Therefore, the external and internal measures of value are interrelated.

Considering other personality characteristics, according to our research, the satisfaction with orofacial appearance measured by OES instrument is related to three big personality traits – extraversion, conscientiousness and neuroticism, however, it is not related to openness and agreeableness. Other authors related self-reported attractiveness of smile to extraversion and anxiety (26). Satisfaction is somewhat higher in people with higher level of extraversion who are full of energy, enthusiastic, and appreciate the participation in social gatherings (16). The subjects with low neuroticism are also more satisfied and those people have more control over their emotions, are emotionally stable and balanced. Therefore, it may be that social, talkative, active, energetic, open-minded, and dominant individuals are able to inhibit complexes, thus influencing the satisfaction with themselves (27, 28). Satisfaction with orofacial appearance is also higher in conscious people who are organized, goal-orientated, and adhere to norms and rules (16). Individuals with these characteristics are most likely to have the will to set priorities such as obtaining and maintaining a beautiful smile by carefully performing the duties imposed by the dentist. This will lead to a beautiful and healthy smile, ultimately, to a greater satisfaction with their overall appearance (16). Psychosocial impact of dental esthetics and orofacial appearances are also related to perfectionism, but mostly due to concern over making mistakes which may also be related to conscientiousness.

The present research has implied that psychosocial influences of altered smile esthetics are not stable and mostly tend to decrease during time. This kind of dissatisfaction is mostly a more or less mild frustration due to an unfulfilled desire. Contrary to expected, positive visual stimuli of commercials showing nice teeth and smile compared to neutral ones do not induce a major change in the perception of the subject's smile esthetics, satisfaction, and psychosocial impacts. Watching commercials at one seating seems difficult to change someone’s mind and his/her opinion about his/her facial esthetics. Regardless of the type of visual stimuli, the respondents of both genders reported less psychosocial impacts for the second time, but the average difference was small, amounting to few scalar points. While completing the initial questionnaire, the respondents may have realized that they were too critical towards themselves regarding their dentofacial esthetics. Therefore, a clinician should be aware that the patients’ opinion and emotions related to his/her own appearance are prone to changes even without any dental interventions. An improvement in acceptance of his/her conditions is generally to be expected. Interestingly, the active group had a less significant reduction than the neutral group, implying that the type of visual stimuli still has an influence, but as an inhibitor of change. There was more reduction of the psychological impact of their dental esthetics with neutral commercials when compared to commercials showing beautiful teeth and smiles. Therefore, commercials portraying individuals who were smiling made some viewers consider their own smile. Some studies confirmed that media ideals cause dissatisfaction, shame, have a negative impact on self-esteem, and may create demand for dental treatments (29, 30). However, there are some studies which refute the abovementioned (31).

The hypothesis that a change in satisfaction related to psychosocial impacts after the exposure to commercials will be bigger in females with higher self-perceived malocclusion severity, perfectionism and neuroticism, and lower self-esteem was not confirmed. The current research shows that a particular group of people, those that are more influenced by commercials, are subjects with higher intellect who are having higher malocclusion severity. A personality trait intellect includes openness to new experiences, esthetic interests, artistic creativity, intellectual curiosity and ability to process novel stimuli quickly. Moderation effect of intellect implies that people that are more esthetically sensitive, intellectually efficient and with higher malocclusion tend to re-evaluate attractiveness of their smile when exposed to high smile esthetics of other people. The general improvement in dentofacial body image in those people is impeded during time. On the other hand, there are people closed to stimulation. They have low perceptiveness and ability to process new information and are not bothered much regardless of their malocclusion severity.

Research demonstrated that media, particularly television commercials, could have an impact on a wider audience. They start demanding different dental procedures (32). The results of psychological testing have shown that one time exposure to stimuli even for a short span, such as in commercials, can cause a change in psychosocial parameters (Error: Reference source not found, Error: Reference source not found). However, the question is how long the psychological impact lasts after watching these commercials. Some studies pointed out that it is enough to show a commercial only for a few times to achieve its maximal commercial success (33-35). Others, however, demonstrate that repetition is very important (36). Advertising is more effective if it is repeated up to 15 times within a two-month period, and the effectiveness increases with a maximum of 12 repetitions in a two-month period. However, if the advertisement is repeated more than 15 times in a two-month period, the efficiency decreases (37). Marketers fully understand that they can have a greater effect on women`s emotions, hence advertisements are designed to target women more than adolescents and elderly population (38, 39).

An area of concern with the study was that the participants maybe wanted to portray themselves in a better light when completing the questionnaires. However, the participants of the study were the students of dental medicine who, taking their education into account, possess a higher level of awareness about dentofacial esthetics. Therefore, it is expected that by focusing on the details, the impact of commercials could be more pronounced and evident. Thus, a suggestion for further research would be to use a broader sample of participants in order to come closer to general population.

Conclusion

Psychosocial influences of malocclusion are not stable and tend to decrease during time even without any dental interventions. However, visual stimuli in form of the exposure to a high smile esthetics of other individuals can inhibit the process in persons with higher malocclusion who have higher cognitive abilities (intellect) including higher esthetical sensitivity and openness to new experiences.