Orthodontic retreatment: positive effects on the patient’s self-esteem and quality of life

ABSTRACT Introduction: An increasing percentage of the world’s population has had access to orthodontic treatment within the last few decades. Consequently, a larger number of patients seeking for correction of their malocclusions, nowadays, present with a history of previous orthodontic therapy. Orthodontists performing retreatments in their practice may have to face additional difficulties, and one of them is treating individuals that may be even more demanding for excellent results and efficient treatments. Objectives: This manuscript discusses the challenges faced when performing orthodontic retreatments. It illustrates a two-phase retreatment of a pre-adolescent and the ortho-surgical retreatment of a young adult with high demands for fast and exceptional results. Finally, this paper elaborates on the positive impacts that these retreatments had on the patients’ self-esteem and quality of life.


INTRODUCTION
Orthodontic treatment has increasingly become available to a larger percentage of the population within the last decades. 1,2 This is due to increased access to oral health care based on the preventive philosophies of contemporary Dentistry, greater longevity of the population, better access to information, higher aesthetic demands of modern society, technological advances in Orthodontics, [3][4][5][6] and lower treatment costs in some countries.
The positive effects of orthodontic treatment on patient's quality of life have been clearly demonstrated. 7,8 Children, adolescents and adults present a better body image and self-confidence related to their appearance after the completion of their orthodontic therapy, thus presenting lower levels of anxiety in social relationships and positive impacts on their self-esteem. 9,10 An increasing proportion of the individuals pursuing orthodontic treatment nowadays present with a history of previous orthodontic therapy. 11 The reasons why patients seek orthodontic retreatment are multifactorial, and may include: desire to further improve esthetics and oral function, inadequate retention phase, maturational changes, unfavorable skeletal growth, failure in diagnosis and treatment planning or poor treatment. 12,13 Orthodontists performing retreatments in their daily practice might have to manage patients presenting higher demands Dental Press J Orthod. 2021;26(5):e21bbo5 Freitas LRP, Oliveira DD -Orthodontic retreatment: positive effects on the patient's self-esteem and quality of life 5 in relation to treatment quality and duration. Therefore, for an orthodontist to retreat successfully, a strong understanding of the difficulties that could lead to failure is necessary.
Furthermore, an objective system to guide the excellence in finishing retreatments could facilitate the clinical management of these cases and increase the chances of success. 4,14 The purpose of this manuscript is to illustrate how the application of the objective criteria of the Brazilian Board of Orthodontics (BBO) assisted in achieving excellent finishing in two orthodontic retreatment patients.

DIAGNOSIS
The parents of a 9.8-year-old female patient sought for a second opinion about the results of an interceptive orthodontic treatment performed in their daughter. According to the parents, the patient had been wearing a removable palatal crib to try to eliminate a thumb-sucking and tongue thrust habits, and to correct an open-bite without success. The patient mentioned that she had been bullied at school due to her unpleasant smile, and her parents reinforced how her self-esteem was low because she did not show her teeth upon smiling. Both her medical and dental history were within normal limits.
Freitas LRP, Oliveira DD -Orthodontic retreatment: positive effects on the patient's self-esteem and quality of life 6 Extraoral evaluation revealed a symmetric face, absence of passive lip sealing, moderately hyperdivergent growth pattern with an increased lower facial height and a slightly convex facial profile. Furthermore, the patient presented a significantly compromised smile esthetics without any maxillary incisors display upon smiling (Fig 1).
Intraoral analysis showed an Angle Class I malocclusion combined with a severe anterior open bite. Although no posterior crossbite was observed, there was a transverse maxillary deficiency, a tapered maxillary arch form and an increased palate depth. Mandibular posterior teeth presented increased lingual inclination as a compensation for the decreased maxillary transverse dimension. Mild crowding on both dental arches was also registered. Periodontally, there was a significant gingival recession on both mandibular central incisors, presence of calculus on the lingual surface of the lower incisors, and a low insertion of the upper lip frenum (Fig 1).

TREATMENT PLANNING AND ORTHODONTIC MECHANICS USED
The previous interceptive orthodontic treatment achieved minor or no results with the use of a removable crib to interrupt the patient's thumb sucking habit, due to the lack of cooperation reported by both parents and the patient herself. Additionally, the removable plate did not address the maxillary transverse deficiency that resulted from the unbalanced muscular pressures observed in patients presenting these types of deleterious oral habits.    The facial profile also improved and a better and well-defined chin-neck line was noted at the end of treatment (Fig 8).
Intraoral post-treatment examination revealed that an ideal occlusion was achieved, with a Class I molar and canine relationship bilaterally, adequate overjet and overbite, coincident midlines and appropriate alignment and leveling of the marginal ridges (Fig 8). Final panoramic radiograph evaluation showed no signs of root resorption, adequate overall alveolar bone levels and appropriate root parallelism (Fig 9).  ing the maintenance of the incisors spatial position (Fig 11). Four years after treatment and two years without wearing any retainers, according to the patient, the results remained stable (Fig 12).      Intraoral evaluation showed a Class II, division 1 malocclusion, canines also in a Class II relationship, reduced anterior overbite and an increased overjet. The patient presented good oral hygiene, but a thin gingival phenotype in the mandibular incisors' region (Fig 13).
Pre-retreatment panoramic radiograph showed that all permanent teeth were present. However, all third molars were impacted in an unfavorable position and without enough space for their eruption (Fig 14). Cephalometric analysis con-  Table 2).     week before surgery (Fig 16). Presurgical orthodontic retreatment lasted nine months.  FMA from 32º to 28º). The spatial position and axial inclination    (Fig 20). Four years after orthodontic retreatment, the results remain stable and the patient continued to report high levels of satisfaction with the multidisciplinary treatment outcomes (Fig 21).

DISCUSSION
When we talk about health, we understand that it is a state of broad subjectivity, so when the subject extends to oral health, this is no different. 16,17 Locker 18 determined oral health as a condition that contributes to physical, psychological and social well-being. Therefore, the individuals would be able to eat, quality of life and well-being. 19 OHRQoL is a multidimensional concept, which allows researchers and practitioners to understand the effects of oral outcomes on people's life dimensions, such as symptoms, functioning, emotional and social well-beings. 20 The increased demand for orthodontic treatment with fixed appliances in the general population has been reported in recent years. 3,19,21 This interest has been justified, in particular, by the population's growing access to dental services.
Furthermore, an increasing number of individuals have made the association between poor oral health and psychosocial problems, which characterizes this population's understanding of their oral problems. 2,4 However, one of the great debates in adult Orthodontics regards the challenges associated with long-term post-treatment stability. A large amount of evidence has demonstrated that even when the orthodontist is able to achieve good occlusion, relapse is a matter. 5,11,22 The scenario becomes worse if iatrogenic issues take place and the orthodontist is inattentive to adequate canine and lateral guidance, as well as appropriate alignment and intercuspation during orthodontic finishing. 5,23 Freitas LRP, Oliveira DD -Orthodontic retreatment: positive effects on the patient's self-esteem and quality of life

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The literature seems to recognize that individuals seeking orthodontic retreatment present themselves disappointed and demotivated during their appointments with the orthodontist. 12,13,24 However, the well-being of these individuals and the impact of orthodontic retreatment on OHRQoL have been not been fully discussed in the literature. 12 The two cases reported in this paper represent good examples of how orthodontic retreatments that achieve well-planed goals may significantly improve the patients' self-esteem. We can see the positive effect of orthodontic therapy on both the functional and aesthetic aspects of both patients, and this in fact results in a positive impact on the quality of life after a second orthodontic intervention. This is because it is known that oral health problems are directly related to negative self-perception of appearance, leading to deterioration of emotional and social behavior. 25,26 Despite the self-reported perception and complaint of these individuals regarding their dental problems, the willingness to undergo orthodontic treatment again may lead to insecurity and uncertainties. Anxiety levels of individuals who are about to begin orthodontic treatment are high and probably negatively influence health-related quality of life. 27,28 On the other hand, the encouragement and the positive reinforcement that comes from the orthodontist may be helpful for the individual in overcoming his/her negative perception and, ultimately, decides to undergo orthodontic retreatment. 23,29 Freitas LRP, Oliveira DD -Orthodontic retreatment: positive effects on the patient's self-esteem and quality of life

CONCLUSION
The population's growing search for orthodontic treatment is of great importance and interest for orthodontists, however we must be aware of the patient's interests and especially of our capacity to perform treatments that bring positive results to their demands. Listening to the patient and knowing the best time for the intervention is certainly the best path for the success of orthodontic treatment, thus avoiding the need for new future interventions.