Malocclusion is a very common oral health issue globally and is a significant factor in people seeking orthodontic treatment.[1] It can present itself in the form of dental crowding, spacing, increase in overjet, deep bite, open bite, crossbite, and sagittal discrepancies, and can impact occlusal function as well as dental aesthetics, self-confidence, social interactions, and oral health-related quality of life.[2] In a systematic review and meta-analysis, it was found that the prevalence of malocclusion was about 56% in the global population and 48% in the Asian population.[3]  Likewise, a global meta-analysis of adolescents revealed that 46% of them needed orthodontic treatment and around 39% of them had a need for malocclusion-related orthodontic treatment.[4]

While orthodontics can enhance occlusion, facial esthetics, and psychosocial health, the fact that a clinically visible malocclusion does not always mean acceptance or uptake of orthodontic treatment.[5] This decision can be difficult and can be affected by a person's perception of their dental appearance, self-esteem, and expected length of treatment, pain or discomfort, cost, fear of appliances, ease of repeated visits, social perceptions, and knowledge of the benefits of treatment.[5] More importantly, objective orthodontic treatment need and perceived orthodontic treatment need can be very different.[6] A study of young adults aged 16–22 revealed that about 71% did not see the need for orthodontics, although orthodontists identified significantly higher treatment needs, thus demonstrating a discrepancy between professional opinion and patient perception.[7]

Treatment acceptance is an important topic to study in youth, as decisions about appearance, employment, social relationships, and personal health care become more independent during this time. Fixed orthodontic appliances are still a very reliable treatment option for many malocclusions, but their aesthetic appearance and the length of treatment commitment can affect the decision to start treatment. Among Chinese young adults aged 18–27 years, only 28% expressed a demand for orthodontic treatment, despite a substantial proportion having moderate or severe objective treatment needs. The most common reason for opting in to treatment was improvement in appearance (78%), while perceived lack of need (64%), prolonged treatment time (18%), and the high cost of treatment (14%) were significant reasons for declining treatment.[8] Subsequent studies have also shown in young adults that psychosocial perceptions of dental aesthetics have a strong predictive value for acceptance of orthodontic treatment.[9]

In Pakistan, the problem is also applicable as more people are seeking orthodontic treatment due to functional and aesthetic reasons. In a recent study in Karachi, Pakistan, which looked at treatment preferences and perceived barriers, 41.2% reported treatment duration as a major barrier to treatment, and aesthetics was reported as an important motivation for seeking orthodontic care.[10] Nevertheless, there is limited specific information regarding factors influencing acceptance of fixed orthodontic treatment in the young adult population of Pakistan. These factors are important, as orthodontic treatment acceptance cannot be solely determined by the clinical severity, and this treatment acceptance may vary between patients with similar malocclusions based on their perceptions, expectations, socioeconomic status, and perceived treatment burden.

Hence, the present study is designed to go beyond the identification of orthodontic treatment need and consider factors that may influence the acceptance of fixed orthodontics for young adults. The study aimed to explore the demographic factors, aesthetic perception, treatment expectations, costs, treatment time, discomfort, social factors, and perceived need as a way of understanding the modifiable barriers and motivations that influence treatment acceptance. This evidence can be used to deliver more patient-centered counselling, reduce misconceptions prior to treatment, and inform strategies for enhancing the uptake of orthodontic treatment in youth and young adults. The aim of this study was to determine the factors influencing acceptance of fixed orthodontic treatment among young adults.

An online cross-sectional survey was carried out with an online questionnaire to evaluate the factors affecting acceptance of fixed orthodontic treatment among young adults. The study was conducted in the Department of Orthodontics of Fatima Jinnah Dental College, and the data was collected between 1^st May 2026 to 31^st May 2026.

The sample size was determined based on an OpenEpi software tool for estimating a single population proportion. A previously reported orthodontic treatment demand of 28% among young adults was used as the anticipated proportion.[8] The minimum sample size required at a 95% confidence level and an absolute precision of 8% was calculated as 121 participants. To account for around 10% potential non-response/incomplete data, the sample was expanded to 135 participants.

A non-probability convenience sampling technique was used. In the study period, the online questionnaire was sent out to eligible young adults via electronic platforms and accessible electronic networks. The age of the participants ranged from 18 to 30 years all of both genders. Participants were required to have sufficient understanding of the questionnaire and access to the electronic survey. The informed consent was given electronically via Google Forms before participants completed the questionnaire.

Those who had already had orthodontic treatment, were currently undergoing orthodontic treatment or had a history of orthognathic surgery were excluded. Those who had craniofacial syndromes, cleft lip or palate, or other severe craniofacial abnormalities were also excluded. Participants who did not consent to be included in the study, did not fill out the questionnaire, or only partially completed it were not included in the final analysis.

A structured, self-administered, electronic questionnaire was developed and the literature searched to gather data on orthodontic treatment acceptance/demand. The questionnaire was sent online via Google Forms and included sections on sociodemographic information, previous dental and orthodontic experiences, self-perception of dental appearance, perceived orthodontic treatment needs, knowledge and awareness of fixed orthodontics, expectations for orthodontic treatment, barriers to orthodontic care, and willingness to seek fixed orthodontics treatment.

Responses were checked for completeness and if incomplete were not included in the final analysis. Participants were asked about their willingness to undergo fixed orthodontic treatment and factors that could influence their decision, including treatment cost, expected treatment duration, anticipated pain or discomfort, appearance of braces, fear or anxiety, frequency of dental visits, perceived effectiveness of treatment, influence of family and friends, social and professional concerns, and perceived improvement in facial or dental aesthetics. The primary outcome was willingness to use fixed orthodontics, which was measured by self-report.

Responses were gathered via Google Forms, checked for completeness and consistency, coded and then reimported into IBM SPSS Statistics version 26 for analysis. Data on continuous scales were summarized as the mean ± standard deviation (SD) for normally distributed data and as the median along with interquartile range (IQR) for non-normally distributed data. The categorical variables were reported as frequencies and percentages. The normality test of continuous variables was performed according to Shapiro–Wilk. The chi-square test was employed to determine the association of categorical variables, such as sex, socioeconomic status, previous dental experience, perceived need for orthodontic treatment, aesthetic concerns, treatment affordability, expected treatment time, pain/discomfort concerns, and social concerns with the acceptance of fixed orthodontic treatment. When the assumptions of the chi-square test were violated, Fisher's exact test was used. The variables that exhibited a significant association with treatment acceptance in univariable analysis were then added to a binary logistic regression model to determine the independent predictors of treatment acceptance. The odds ratios with 95% confidence intervals were reported. Values of p<0.05 were selected as statistical significance.

A total of 135 young adults were included in the study. The mean age was 23.8 ± 3.2 years, with the largest proportion aged 22–25 years (43.7%). The majority of participants were females (57.8%), undergraduate-educated (52.6%), middle socioeconomic status (54.1%), and urban living (74.8%). (Table 1)

In terms of dental and orthodontic attributes, 80.7% of participants have visited a dentist previously, and 34.8% have consulted an orthodontist. Perceived malocclusion was reported by 67.4%, dissatisfaction with dental appearance by 62.2%, and perceived need for orthodontic treatment by 68.1%. The concerns of dental alignment and facial aesthetics were reported by 63.7% and 54.1%, respectively. Fixed orthodontic knowledge level was good in 45.2%, moderate in 38.5%, and poor in 16.3% of the participants. (Table 2)

The most common consideration related to treatment was treatment cost (71.1%), followed by the length of treatment (64.4%) and fear of pain or discomfort (51.1%). Concerns regarding brace appearance, frequent dental visits, and treatment-related anxiety were reported by 43.0%, 40.0%, and 33.3%, respectively. The majority of participants felt that orthodontic treatment would enhance dental esthetics (83.0%) and oral function (67.4%), and 36.3% were encouraged by family and friends. (Table 3)

Fixed orthodontic treatment was consented to by 63% of the respondents, while 38.5% refused it. Acceptance was significantly associated with improvement in dental aesthetics (p=0.018), improvement in facial appearance (p=0.033), perceived need for treatment (81.9% vs. 46.2%, p<0.001), affordable treatment cost (p=0.011), and acceptable treatment duration (p=0.039). Participants who refused treatment were significantly more likely to experience fear of pain/discomfort (p<0.001) and be concerned about the appearance of the brace (p<0.001) than were those who accepted treatment. (Table 4)

Acceptance was significantly higher among people with middle/high socioeconomic status (p=0.018), perceived malocclusion (p=0.001), dissatisfaction with dental appearance (p=0.002), perceived need for orthodontic treatment (p<0.001), previous orthodontic consultation (p=0.009), and good treatment awareness (p=0.019). There were no significant differences found for age group or sex. (Table 5)

Perceived need for orthodontic treatment was the strongest independent factor associated with acceptance in the binary logistic regression (p<0.001). Other factors that were independently correlated with higher scores of acceptances included dissatisfaction with the appearance of their teeth, perceived malocclusion, good awareness, middle-high socioeconomic status, and perceived affordability of treatment. Fear of pain/discomfort and concern about brace appearance, however, were independently related to lower acceptance. (Table 6)

Table 1. Sociodemographic characteristics of study participants (n=135)

Table 2. Dental and orthodontic characteristics and perceptions of participants (n=135)

Table 3. Treatment-related expectations and perceived barriers to fixed orthodontic treatment (n=135)

Table 4. Reasons for accepting or declining fixed orthodontic treatment

Table 5. Association between selected characteristics and acceptance of fixed orthodontic treatment (n=135)

Table 6. Binary logistic regression analysis of factors associated with acceptance of fixed orthodontic treatment

In the present study, the factors associated with the acceptance of fixed orthodontic treatment among young adults were assessed, and 61.5% of the young adults were willing to receive fixed orthodontics. Acceptance was significantly associated with perceived malocclusion, dissatisfaction with dental appearance, perceived need for orthodontic treatment, previous orthodontic consultation, awareness, socioeconomic status, treatment affordability, and expectations regarding treatment. On the other hand, the prospect of pain or discomfort and concerns about the appearance of fixed appliances arose as significant deterrents. The strongest independent predictor of acceptance on multivariable analysis was perceived need for orthodontic treatment, whereas fear of pain/discomfort and concern about how braces looked were independently associated with less acceptance.

The relatively high treatment acceptance rates found in the present study suggest that young adults are more likely to see orthodontic treatment as a component of dental and facial aesthetics rather than simply a remedy for functional issues. This is similar to a study conducted by Anagnostou et al. in 2025 involving 270 young adults (aged 18-30 years), where psychological consequences of dental aesthetics were the only significant predictor of willingness to undergo orthodontic treatment (p<0.001). The authors also concluded that fear, embarrassment about appearing during treatment, cost, length of treatment, and lack of information were factors that delayed treatment.[9] It is the similarity that is particularly relevant, as our study also showed that there was a strong relationship between dissatisfaction with dental appearance and perceived need, suggesting that this subjective psychosocial need can play a more important role than demographic factors in treatment uptake.

The strong relationship between perceived need and treatment acceptance in our study is also consistent with findings from Saudi Arabia. In a cross-sectional study of 2022, the researchers found that adults were far more aware of the need for orthodontic treatment than children, with 78.5% of adults indicating a need for treatment, while aesthetic appearance was the main reason for adults to seek treatment (58.6%).[11]  Likewise, our participants who perceived a need for orthodontic treatment had significantly higher acceptance than those who did not perceive a need (73.9% vs. 34.9%), and perceived need continued to be a factor that was independently associated with acceptance after the adjustments were made. The results indicate that orthodontic counselling needs to focus on the patient's perception of the dental appearance and need for treatment as well as the professional assessment of malocclusion.

In our study, there were many aesthetic considerations. Nearly two-thirds of participants were dissatisfied with their dental appearance, and acceptance was significantly greater among those reporting aesthetic dissatisfaction. This observation agrees with a 2024 report on adult orthodontics in the United Kingdom and Republic of Ireland, in which improving the appearance of the teeth was the most frequently selected motivation (82%). The most popular information requests were for the duration of treatment (64%), expected treatment outcome (56%), type of appliance (55%), and cost (52%).[12] Similarly, a 2024 survey of patients aged 18 and older undergoing fixed orthodontics showed that the top expectations were: teeth straightening (83.3%), improved appearance (73.6%), and improved smile (71.5%). Aesthetics of the appliance (30.9%) and lengthy treatment time (27.6%) were the most common negative attributes.[13] Therefore, the current results confirm that the aesthetic value of the treatment itself plays a part in treatment acceptance and reinforce a role for aesthetics in the orthodontic decision-making process.

The literature also confirms that concern about the look of fixed braces significantly decreased acceptance, as we found in our study. Anagnostou et al. noted that embarrassment with the way one looks during treatment was an important factor associated with delaying orthodontic therapy in the young adult population.[9]  A 2025 questionnaire study on reasons for seeking adult orthodontics revealed that cosmetic improvement was the main reason for seeking orthodontic treatment, while the time needed, cost, and treatment appearance were identified as major barriers.[14] These observations are especially important for youth in their teens and early twenties, for whom personal and professional presentation is of great importance. Therefore, the present finding indicates that it is important to discuss cosmetic options and realistic expectations of appliance visibility during treatment, rather than assuming that a strong desire for aesthetic improvement equates to a willingness to accept the conventional fixed appliances.

Another key determinant in our study was treatment cost. Those who found orthodontic treatment affordable were more likely to accept treatment, and middle/high SS was independently associated with greater acceptance. The result is similar to one of the most recent and discrete-choice studies in the British Dental Journal of 2022 that showed family income and cost to the patient were among the most significant attributes that affected orthodontic treatment choices. Among participants willing to undergo treatment, 63.6% were willing to pay for it, and most were willing to pay up to £2,000.[15] Likewise, a 2021 study investigating preference for adult orthodontic treatment revealed that the cost of treatment was an important factor in treatment decisions, with participants willing to pay more for aesthetic appliances than for conventional fixed metal appliances.[16] Our study findings are consistent with the studies that show that orthodontics is a large financial commitment and that the affordability of treatment may affect the intention to accept treatment.

More recent preference studies have also shown the importance of cost. In China, a total of 349 malocclusion young adults were involved in a discrete choice experiment in which treatment cost, comfort, and aesthetics were found to be important factors to consider when choosing orthodontic treatment. Lower-income participants were more interested in cost, and a greater emphasis was placed on comfort and aesthetics by participants.[17] This is particularly applicable to our results as affordability was positively related to acceptance, which may indicate that financial counselling, fee transparency and flexible payment options can help overcome an important modifiable barrier to orthodontic treatment.

Another major negative predictor in the current study was fear of pain/comfort. Individuals who indicated discomfort were significantly less likely to accept fixed orthodontic treatment. Those who answered fear of discomfort were significantly less likely to accept fixed orthodontic treatment. This result is aligned with the Saudi Arabian study for 2022, which revealed that cost, duration of treatment, and pain were among the primary challenges for orthodontic treatment.[18] It is also consistent with a study by Gulzar et al., published in 2026, in Pakistan, where the expected treatment duration was the most commonly mentioned barrier amongst adults, and fear of anticipated pain was also reported as a significant concern. In that research, the main reason people started treatment was for their appearance.[10] The agreement between our findings and the Pakistani data is especially significant because perceptions regarding treatment burden can be shaped by socioeconomic factors, access to dental care, or prior experiences with dental care in Pakistan.

The multivariable model did not show that sex or age were individually related to treatment acceptance, interestingly. The result is in line with that of Anagnostou et al., who did not find gender or age to be significant factors that would affect the willingness of young adults to seek orthodontic care.[9] It was also found to be generally applicable to a 2026 study on 1,299 university students in Northern China, which found that there were no significant differences in willingness to receive orthodontic treatment among the students according to their demographic characteristics.[19] Instead, service quality, satisfaction, and social norms were significant determinants of acceptance. The results indicate that modifiable perceptions and experiences might play a greater role than basic demographics in determining orthodontic acceptance.

Likewise, in the 2024 UK/ Ireland adult orthodontic survey, 31% of respondents indicated social media as a social influence, and 31% indicated that the perception of braces being socially accepted was a social influence.[12] Thus, it seems that the acceptance of orthodontic treatment by young adults is related to a wider context of society that includes social norms, peer perceptions, appearance and professional presentation, as well as treatment needs.

LIMITATIONS

This study had some limitations. The cross-sectional design enabled associations to be considered but not the causality between the factors identified and treatment acceptance. The data were gathered using a self-administered electronic questionnaire (Google Forms), and the self-report answers may therefore have been subject to recall, social desirability, or response bias. Less proficiency with electronic questionnaires and less access to smartphones and internet service may have also resulted in fewer participants. A questionnaire was designed from the literature and reviewed for clarity, but a formally validated instrument was not used. Furthermore, financial status and family factors may have influenced perceptions of both affordability and acceptance of treatment.

Acceptance of fixed orthodontic treatment was observed in 61.5% of young adults. Important positive factors associated with acceptance were perceived need for orthodontic treatment, dissatisfaction with dental appearance, perceived malocclusion, better treatment awareness, higher socioeconomic status, and affordability. Conversely, fear of pain or discomfort and concern about the appearance of braces reduced treatment acceptance. Addressing treatment-related fears, improving patient education, and providing affordable treatment options may improve acceptance of fixed orthodontic treatment among young adults.

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