Type of the Paper (Article Journal of Baghdad College of Dentistry, Vol. 34, No. 1 (2022), ISSN (P): 1817-1869, ISSN (E): 2311-5270 12 Research Article Compliance of patients with Class III malocclusion to orthodontic treatment Zaid Alaa Abdulhussein 1,*, Alev Aksoy 1 1 Süleyman Demirel University, Faculty of Dentistry, Department of Orthodontics, 32100, Isparta, Tur- key * Correspondence: drzaidalaa@gmail.com Abstract: Background: Although the new treatment methods developed in recent years are aiming to minimize the need for cooperation of the patients; however, the latter still im- portant factor the treatment. The aim of the study was to evaluate the cooperation level of Class III malocclusion patients with orthodontic treatment. Materials and methods: This study followed a cross-sectional style; the targeted population was patients with Class III malocclu- sion who were treated with three different types of orthopaedic appliances. Four question- naires were delivered to the patient, patient’s parents, and orthodontists. Statistical analyses of the study were performed with SPSS 20.0 software. Descriptive analyses were presented using frequency, percentage, mean, and standard deviation. Results: The study included a total of 183 orthodontic patients in the final analysis. Slightly more than half of the participants were females (52.46%; n=96) and the rest were male (47.54%; n=87). The highest frequency according to the device type was FM (50.8%) followed by CC (31.1%) while FM+RME wearer was 18.1%. Male expressed significantly higher (p <0.05) cooperation and tendency levels to- wards treatment than females. Cooperation level was also significantly associated with the parents’ monitoring and motivation. Conclusion: Males had higher levels of treatment desire and cooperation than females during the treatment of Class III malocclusion. In addition, re- sults emphasized the role of the motivational effect of the parent on the positive cooperation of the patients. Keywords: Questionnaire, Patients Compliance, Class III Malocclusion Introduction Class III malocclusion is one of the most difficult malocclusions in terms of diagnosis and treatment especially in mixed and late deciduous dentation (1). It was first described by Angel according to the posi- tion of the molars during occlusion (2). Later, Tweed further classified Class III malocclusion into two sub- categories; pseudo Class III malocclusion and skeletal Class III malocclusion (2). The early intervention during the growth period of a child with class III skeletal malocclusion using orthopaedic appliances (extra oral or intra oral) is a very common treatment approach with highly suc- cessful results. However, these devices are not aesthetically acceptable and require full cooperation from the young patients (3-6). According to Proffit, Class III malocclusion treatment should be started as soon as possible with the ideal age of 8 years (7, 8). In most cases, the best time to start the treatment of Class III malocclusion is when the diagnosis is confirmed by the orthodontist (9). The importance of patient cooperation for the success of orthodontic treatment has been emphasized by many researchers (10-12). From orthodontic point of view, the cooperative patient is described as an in- dividual with good oral hygiene, wears the devices as they are told, follows an appropriate diet, and Received date: 12-2-2022 Accepted date: 8-3-2022 Published date: 15-3-2022 Copyright: © 2022 by the authors. Submitted for possible open access publication under the terms and con- ditions of the Creative Commons At- tribution (CC BY) license (https://cre- ativecommons.org/licenses/by/4.0/). https://doi.org/10.26477/jbcd .v34i1.3087 mailto:drzaidalaa@gmail.com https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ https://doi.org/10.26477/jbcd.v34i1.3087 https://doi.org/10.26477/jbcd.v34i1.3087 J. Bagh. Coll. Dent. Vol. 34, No. 1. 2022 Abdulhussein and Aksoy 13 fallows the instruction given by the orthodontist (13). In addition, the cooperative patient could be described as the patient who comply to the given appointments on time, maintains optimum oral hygiene, uses the device as instructed, and takes care of the appliances whether fixed or removable (10, 11). Usually, the patient cooperation may be affected by some factors such as sex, age, social class, personality and severity of malocclusion. A problem that may occur in cooperation may lead to deviation from the ideal treatment plan, prolongation of the treatment period and even early termination of the treatment without reaching desirable outcomes. The degree of the expected cooperation from the orthodontic patient depends on many factors such as age, sex, socioeconomic status, demographic factors (14, 15), patient-family relations (16-18), patient and fam- ily's desire for orthodontic treatment, patient's personality characteristics (14, 15, 18-20), and perception of mal- occlusion (21). Allan and Hodgson stated that age is important in predicting patient’s cooperation. Since pre-adolescent children are more prone to accept and implement the demands of their families, it is pos- sible to provide cooperation with the influence of the family (14). Some studies have suggested that patient sex my help to predict the patient cooperation during the treatment as females appears to be more adaptable to the treatment than males. Nevertheless, the satisfac- tion level with the appearance is lower in females than males, thus this feature could negatively affect the use of special appliances needed during the treatment (22). Additionally, the socio-economic status may have an effect on patient’s cooperation. It has been suggested that patients with high socio-economic level cooperate better than patients with low socio-economic level (23). The aim of the study was to evaluate the compliance of patients with Class III malocclusion to or- thodontic treatment using different types of orthopaedic appliances. Materials and Methods Study design This study followed a cross-sectional design and was conducted after obtaining the ethical approval from Faculty of Medicine Clinical Research Ethics Committee, Süleyman Demirel University. It was car- ried out in the Department of Orthodontics, Faculty of Dentistry, Süleyman Demirel University from Sep- tember 2019 to July 2020 The targeted population was patients with Class III malocclusion who were treated with three dif- ferent types of orthopaedic appliances. After obtaining a signed consent from each patient’s guardian, a questionnaire was delivered to the patient, patient’s parents and the treating orthodontist. J. Bagh. Coll. Dent. Vol. 34, No. 1. 2022 Abdulhussein and Aksoy 14 Study population The following information was recorded for each patient including date of birth, sex, educational backgrounds and occupations of their parents. Eligibility for enrolment of the patients was decided ac- cording to the following inclusion/exclusion criteria: Inclusion criteria: 1. The absence of any craniofacial anomalies congenital or acquired deformity, any muscle disease or sys- temic disorders. 2. No previous orthodontic treatment. 3. Patients between the ages of 9-17 years. 4. The presence of Class III dental or skeletal malocclusion. 5. Late mixed deciduous or permanent dentition, 6. The treatment is carried either by chin cup (CC), face mask (FM) or face mask with rapid maxillary expan- sion (FM+RME). Exclusion criteria: 1. The presence of either Class I or Class II anomaly, 2. Complete completion of the skeletal growth-development period (17 years and over), 3. The presence of congenital missing teeth 4. Having any systemic or psychological disorder, 5. Patients receiving dental or skeletal Class III treatment but not using FM, CC or FM+RME, 6. Treatment time is less than 4 months. Elements of the questionnaire The questioners used in the study were the Orthodontic Attitude Survey-OAS (Questionnaire 1), the Orthodontic Locus of Control Scale (OLOCS) (Questionnaire 2) Parent Questionnaire (Questionnaire 3) and Orthodontic Patient Cooperation Scale-OPCS (Questionnaire4). These questionnaires were adopted and translated to Turkish. Their reliability and validity were determined by previous studies (11, 24). In this study, questionnaire forms were filled during the treatment. Before filling out the question- naires, all individuals were informed verbally by the main investigator that they should carefully read all the questions, answer them honestly, not get help from anyone while answering the questions and they should answer thoughtfully expressing their opinions (25). J. Bagh. Coll. Dent. Vol. 34, No. 1. 2022 Abdulhussein and Aksoy 15 The first questionnaire (Orthodontic Attitude Survey-OAS) was composed of 21 questions dedicated to evaluate the attitude and behaviour towards orthodontic treatment. A score of 1-5 was given to each ques- tion. The section regarding the appliance use consisted of five questions with a score between 5 and 25. The section regarding the patient’s opinion towards his/her own occlusion was consisted of two questions with score 5 to 10. The importance of the occlusion in the orthodontic treatment is presented in 16th ques- tion. The patient’s prospective of the treatment consisted of four questions with average score value of 5 to 20. The 18th question asked about the features the patient did not like in their dentation. The 20th question asked about the person who had the effect on the starting of treatment. The second questionnaire consisted of 31-item adapted from Orthodontic Locus of Control Scale (OLOCS)(26) and translated from English to Turkish (Figure 1) aimed to evaluate the attitude of the patients towered their own occlusion and their awareness about the responsibilities required by them during the treatment. In addition, the degree to which the patients are affected by internal or external factors (per- sonal and environmental factors) was assessed. All questions were scored according to 5-points Likert scale. External locus of control consisted of four questions (#10, #14, and #17). Theoretically expected point value was in the range of 5-20. Internal locus of control consisted of a total of ten questions numbered (#1 to #7, #9, #16, #22) with an expected score in the range of 5-45. The external family locus of control consisted of seven questions (#18 to #22, #24). The theoretically expected score range here is 5-30. The third questionnaire, filled out by the parents, included questions relating to the behaviour of the child. The scoring system was made with 5-points Likert scale. The first question was about the treatment expenses and how it had been paid. The second question was related to the idea about the treatment need, the third question was about the child desire for treatment, the fourth question was about the child idea about his/her teeth, and the fifth question was about the parents’ opinion about the need for treatment, while the sixth question asked about the patient attitude towards the treatment. The fourth questionnaire was filed by the orthodontist who agreed to participate in the study. Slakter et al. designed this scale in relation to appointment tracking and appliance storage. It examined the effect of oral hygiene on the treatment approach to measure the individual's cooperation. Five questions of OPCS containing negative statements are scored in reverse and five questions were evaluated as positive a score of 1 to 5 point are given to each question. Sample size calculation G Power 9.1.2 (Universitaet Kiel, Germany) software was used for estimating sample size of the study. Power analysis was performed using the scale score and cooperation information obtained from the pilot studies. Using the behavioural scale information, the effect size was calculated as 0.63. The effect size was calculated as 0.41 using the control scale score. The minimum effect size was chosen for the larger sample. For CC, face mask and FM with RME device types, the F test and one-way analysis of variance were selected, the margin of error was 5% and the power value was 0.95, and the sample size was J. Bagh. Coll. Dent. Vol. 34, No. 1. 2022 Abdulhussein and Aksoy 16 calculated as 32 for each group. During the study period, this value was exceeded and a higher number of study groups were determined. Figure 1: Orthodontic Locus of Control Scale (OLOCS)(26) questionnaire Statistical analysis Statistical analyses of the study were performed with SPSS 20.0 (IBM Inc., Chicago, IL, USA) pro- gram. Descriptive measures were presented using tables as frequency, percentage, mean, and standard deviation. The conformity of the questionnaire scores to the normal distribution was analysed by the Kol- mogorov-Smirnov method. Student T-test was used for comparisons between two independent groups. Chi-square analysis with Monte Carlo correction was used to determine the relationships between cate- gorical variables, and Pearson’s correlation analysis was used to determine the relationships between nu- merical variables. The type-I error value was taken as 5% in the entire study, and the p <0.05 value was considered statistically significant. J. Bagh. Coll. Dent. Vol. 34, No. 1. 2022 Abdulhussein and Aksoy 17 Results This study included a total of 183 orthodontic patients in the final analysis. Females represented 52.46% (n=96) and the rest were males (47.54%; n=87). The most common device type was FM (50.8%; n=93) followed by CC (31.1%) while FM+RME was the lowest (18.1%). There was no significant difference of device type distribution according to sex (Table.1). Table 1: Device distribution according to sex Device Type Sex p value* Male Female Chin cup 33 (37.90%) 24 (25.00%) 0.116 Face mask 42 (48.30%) 51 (53.10%) Face mask+ rapid maxillary expansion 12 (13.80%) 21 (21.90%) * Significance at p <0.05 by Chi square test A significant difference was observed between male and female in the score regarding the treatment desire and preferences in all three groups. Briefly, male preferred having straight teeth over summer va- cation whatever the device type used. While 37.5% of females in the CC group (p<0.001), FM group 23.5% (p=0.001), FM+RME group 28.6% (p=0.041) did not prefer the orthodontic treatment (Table2). Table.2: Orthodontic treatment preference according to device types Device Type Sex p value* Male Female Chin cup Summer vacation 0 (0.00%) 9 (37.50%) <0.001* Straight Teeth 33 (100.00%) 15 (62.50%) Face mask Summer vacation 0 (0.00%) 12 (23.50%) 0.001* Straight Teeth 42 (100.00%) 39 (76.50%) Face mask+ rapid maxillary expansion Summer vacation 0 (0.00%) 6 (28.60%) 0.041* Straight Teeth 12 (100.00%) 15 (71.40%) * Significance at p <0.05 by Chi square test The importance given by the patient to their own occlusion for those using CC and RME devices did not differ significantly between sexes (Table 3). While in patient using FM, 50% of the males considered their occlusion very important and 82% of the females stated that their occlusion is absolutely important. In patients using a CC device, the importance giving to the orthodontist instructions regarding the treat- ment was found to be higher in males, while the "somewhat important" option was selected by 12.5% of females (p=0.002). In patients using FM and FM+RME, there was not significantly different between both sexes (Table.4). The need for orthodontic treatment realization rate in females who used CC device was found to be significantly higher (p=0.018) than male; however, there was no significant difference in patients using FM. The frequency of females, using FM+RME device, who realized the need for treatment was found to be significantly high (p<0.001) as compared to male (Table.5). On the other hand, there was no significant difference according to the sex regarding the person who had the impact on the decision to start the or- thodontic treatment (Table.6). J. Bagh. Coll. Dent. Vol. 34, No. 1. 2022 Abdulhussein and Aksoy 18 Table.3: Importance of occlusion according to sex and device types Device Type Sex p value* Male Female Chin cup Absolutely Important 21 (63.60%) 21 (87.50%) 0.459 Very important 12 (36.40%) 0 (0.00%) Important 0 (0.00%) 3 (12.50%) Face mask Absolutely Important 21 (50.00%) 42 (82.40%) 0.020* Very important 21 (50.00%) 6 (11.80%) Important 0 (0.00%) 3 (5.90%) Face mask+ rapid maxillary expansion Absolutely Important 9 (75.00%) 12 (57.10%) 0.092 Very important 3 (25.00%) 3 (14.30%) Important 0 (0.00%) 3 (14.30%) Somewhat Important 0 (0.00%) 3 (14.30%) * Significance at p <0.05 by Chi square test Table 4: Consideration of orthodontist instruction according to device types Device Type Sex p value* Male Female Chin cup Very important 30 (90.90%) 12 (50.00%) 0.002* Important 3 (9.10%) 9 (37.50%) Somewhat Important 0 (0.00%) 3 (12.50%) Face mask Very important 33 (100.00%) 24 (100.00%) 0.124 Important 33 (78.60%) 30 (58.80%) Somewhat Important 6 (14.30%) 15 (29.40%) Face mask+ rapid maxillary expansion Very important 12 (100.00%) 18 (85.70%) 0.170 Important 0 (0.00%) 3 (14.30%) * Significance at p <0.05 by Chi square test The scale scores were compared according to sex (Table.7). The scale scores obtained from the ques- tionnaire forms filled by patients, parents and orthodontist did not differ significantly between both sexes. In the correlation analysis performed between the scale scores, a low level of significant and positive correlation was found between the behaviour score and the other scales (Table.8). The patients' behav- ioural cooperation scale and orthodontic treatment control score were low and positive (r=0.163; p=0.027). A significant and positive correlation were observed in association with parents’ cooperation (r=0.154; of p=0.037) and with the patient-orthodontist cooperation (r=0.577; p<0.001). There was no significant rela- tionship between the control scale and the parent and orthodontist cooperation scales. A low level of pos- itive correlation (r=0.176; p=0.017) was found between parent and orthodontist cooperation scales. J. Bagh. Coll. Dent. Vol. 34, No. 1. 2022 Abdulhussein and Aksoy 19 Table 5: Orthodontic treatment needs according to device types Device Type Sex p value* Male Female Chin cup By the warning of my friends 3 (9.10%) 0 (0.00%) 0.018* By the warning of the dentist 27 (81.80%) 18 (75.00%) By the warning of my family 3 (9.10%) 3 (12.50%) I notice it myself 0 (0.00%) 3 (12.50%) Face mask By the warning of the dentist 33 (78.60%) 39 (76.50%) 0.451 By the warning of my family 9 (21.40%) 9 (17.60%) I notice it myself 0 (0.00%) 3 (5.90%) Face mask+ rapid maxillary expansion By the warning of the dentist 6 (50.00%) 3 (14.30%) <0.001* By the warning of my family 6 (50.00%) 3 (14.30%) I notice it myself 0 (0.00%) 15 (71.40%) * Significance at p <0.05 by Chi square test Table 6: People who influence the treatment decision by device type Device Type Sex p value* Male Female Chin cup Dentist advice 12 (36.40%) 9 (37.50%) 0.931 Family advice 21 (63.60%) 15 (62.50%) Face mask Dentist advice 15 (35.70%) 24 (47.10%) 0.635 Family advice 27 (64.30%) 24 (47.10%) My self 0 (0.00%) 3 (5.90%) Face mask+ rapid maxillary expansion Friends’ advice 3 (25.00%) 0 (0.00%) 0.195 Dentist’s advice 0 (0.00%) 6 (28.60%) Family advice 9 (75.00%) 12 (57.10%) My self 0 (0.00%) 3 (14.30%) * Significance at p <0.05 by Chi square test Table 7: Scale general scores by sex in detail on device types Device Type Sex Behaviour Score Mean ± SD Control Score Mean ± SD Parent Score Mean ± SD Orthodontist Score Mean ± SD Chin cup Male 64.09±7.83 95.09±11.75 16.90±2.54 21.96±4.39 Female 66.00±6.17 96.75±5.49 16.37±3.18 22.04±4.41 p value 0.326 0.524 0.485 0.952 Face mask Male 62.33±8.55 96.28±9.67 17.35±2.80 22.21±4.28 Female 62.86±10.69 97.88±12.54 16.25±2.69 22.01±4.19 p value 0.796 0.501 0.057 0.826 Face mask+ rapid maxillary expansion Male 62.75±2.00 101.00±4.45 16.91±2.35 20.50±0.90 Female 64.14±6.27 94.66±10.59 15.80±3.01 20.00±2.81 p value 0.463 0.059 0.282 0.565 J. Bagh. Coll. Dent. Vol. 34, No. 1. 2022 Abdulhussein and Aksoy 20 Table 8: Correlation values between scale scores Control Score Parent Score Orthodontist Score Behaviour Score r 0.163 0.154 0.577 p 0.027* 0.037* <0.001* Control Score r -0.013 -0.036 p 0.865 0.633 Parent Score r 0.176 p 0.017* r: correlation coefficient * Significance at p <0.05 by Pearson’s correlation Discussion Class III malocclusion considered one of the challenging conditions in terms of diagnosis and treat- ment. Treatment could be started during the period of growth using either extra oral or intraoral appli- ances in order to stimulate or modify the growth of the maxilla or inhibit the growth of the mandible. These appliances utilize the orthodontic force to correct the sagittal disharmony between the maxilla and the mandible. Due to the fact these types of appliances controlled mainly by the patient and should wear the appliance for at least 14-18 hours per day, therefore, cooperation of the patient is required to achieve desirable outcomes. Nevertheless, compliance of the patient is not easily obtained due to the fact that the design of these appliances is bulky and not aesthetically acceptable which is not tolerated well by the child. In addition, the young patients are potentially subjected to bullying by their peers which increase the difficulty to convince the child to wear the appliance. Indeed, psychological analyses are useful tools for measuring patient’s cooperation during treat- ment and guide the orthodontists about patient-specific treatment approach. In our study, the aim was to measure and correlate the cooperation for three types of appliances used for treatment of Class III maloc- clusion. This was achieved by using four, previously validated, questionnaires including OAS, OLOCS, CCE, OPCS (27). Patients selected for this study had started the treatment for at least 4 months depending on the results obtained by Slakter et.al which stated that in order to measure the cooperation of the patient a period of 4 to 8 months should passed in order to establish a solid communication between the patient and the orthodontist (28). While some studies stated that the socio-economic level is a crucial factor for patients’ cooperation, other studies claimed the opposite (23, 29). Sergal et al., suggested that the socio-economic status of the family is not a detrimental factor to obtain cooperation of the patient (30). Results of current study could not con- firm nor contradict this notion since treatment expenses were covered by the health assurance provided by the government i.e., standardized the socio-economic factor for all the patients included in the study. J. Bagh. Coll. Dent. Vol. 34, No. 1. 2022 Abdulhussein and Aksoy 21 Age of the patient is another factor that could affect the level of cooperation. Previous studies showed heterogeneity when selecting the age limit. For instance, some reported an age range of 12-15 years (31) or 11-14 years (32-35) or the age limit was set at 16 years (36, 37), while in other studies age standard- izing was preferred (24, 28, 38, 39). A questionnaire-based study conducted by Verda et al. at Istanbul University, the age limit was determined between 11 and 16 (40). In this study, the age range was determined between 9 and 17 years due to the fact that Class III malocclusion treatment mainly starts at the age of 9 years old. These variations in age groups could explain the differences in results obtained by the aforementioned studies. According to available literature, orthodontic treatment is more accepted by the females who also more cooperative compare to the males of the same treatment groups. This could be explained that the female are more concerned about their appearance and the aesthetic of their dentation than male (41, 42). This notion has been supported by results of Karaman et al who showed that the females used the ortho- dontic appliances as instructed by the orthodontist and tend to be more cooperative than male during the treatment (43). This was inconsistent with results of the current study which indicated that males preferred the orthodontic treatment and had a desire the treatment more than the females in all the three types of devices included in the study. While only 62.5% of CC, 76.5% FM and 71.6% FM+MRE the girls preferred the orthodontic treatment. According to a previous study, 80.9% of the patient were motivated by their families; also the ma- jority of the patient, even in the presence of pain or discomfort during the appliance application, continued to wear the appliances which indicate that a well-motivated patient tends to show a higher degree of cooperation (43). In this study the collective answers of both the patients and the parents showed that the majority of the patients were well motivated by their families. In addition, 56.8% of the parents insisted on the treatment even if the patient did not want the treatment at the beginning. Further, 85.2% of the patient continued wearing their appliance in order to obtain good-looking dentation which suggested a high motivational level provided by their families. Conclusion It can be concluded that males had higher levels of treatment desire and cooperation than females during the treatment of Class III malocclusion i.e., sex could be a predictive independent variable for ex- pecting patient’s cooperation during orthodontic treatment. In addition, results emphasized the role of the motivational effect of the parent on the positive cooperation of the patients. Conflict of interest: None. J. Bagh. Coll. Dent. Vol. 34, No. 1. 2022 Abdulhussein and Aksoy 22 References 1. JAM J. Class III Malocclusion. Orthodontics and Dentofacial Orthodontics. United States of America: Needham Press, Inc.; 2002. 2. Bishara SE. Treatment of Class III Malocclusion in the Primary and Mixed Dentitions Text Book of orthodontics W.B Saunders Company 2001: 376. 3. Nardoni DN, Siqueira DF, Cardoso Mde A and Capelozza Filho L. Cephalometric variables used to predict the success of interceptive treatment with rapid maxillary expansion and face mask. A longitudinal study. Dental Press J Orthod. 2015;20:85- 96. 4. Baccetti T, Franchi L and McNamara JA, Jr. Cephalometric variables predicting the long-term success or failure of combined rapid maxillary expansion and facial mask therapy. Am J Orthod Dentofacial Orthop. 2004;126:16-22. 5. Gardner GE and Kronman JH. Cranioskeletal displacements caused by rapid palatal expansion in the rhesus monkey. Am J Orthod. 1971;59:146-55. 6. Ghiz MA, Ngan P and Gunel E. Cephalometric variables to predict future success of early orthopedic Class III treatment. Am J Orthod Dentofacial Orthop. 2005;127:301-6. 7. Tokagi S and Asai Y. Treatment of Class III malocclusions in the Alexander discipline. Semin Orthod. 2001;7:107-116. 8. Profitt W and Fields H. Contemporary orthodontics 3RD ed. United States of America, Mosby-Year Book Inc 1999:478-523. 9. Kassisieh SA. Age Differences in the Response to Maxillary Protraction Therapy: Texas, UNITED STATES; 1994. 10. Bishara SE and Ziaja RR. Functional appliances: a review. Am J Orthod Dentofacial Orthop. 1989;95:250-8. 11. Egolf RJ, BeGole EA and Upshaw HS. Factors associated with orthodontic patient compliance with intraoral elastic and headgear wear. Am J Orthod. 1990;97:336-348. 12. Sinha PK, Nanda RS and McNeil DW. Perceived orthodontist behaviors that predict patient satisfaction, orthodontist-patient relationship, and patient adherence in orthodontic treatment. Am J Orthod Dentofacial Orthop. 1996;110:370-7. 13. Weaver N, Glover K, Major P, Varnhagen C and Grace M. Age limitation on provision of orthopedic therapy and orthognathic surgery. Am J Orthod Dentofacial Orthop. 1998;113:156-64. 14. Allan TK and Hodgson EW. The use of personality measurements as a determinant of patient cooperation in an orthodontic practice. Am J Orthod. 1968;54:433-440. 15. Sergl HG, Klages U and Zentner A. Functional and social discomfort during orthodontic treatment--effects on compliance and prediction of patients' adaptation by personality variables. Eur J Orthod. 2000;22:307-15. 16. Schott TC and Göz G. Young patients' attitudes toward removable appliance wear times, wear-time instructions and electronic wear-time measurements--results of a questionnaire study. J Orofac Orthop. 2010;71:108-16. 17. Mangoury NH. Orthodontic cooperation. Am J Orthod. 1981;80:604-22. 18. Sergl H, Klages U and Pempera J. On the prediction of dentist-evaluated patient compliance in orthodontics. Eur J Orthod. 1992;14:463-468. 19. Ast DB, Carlos JP and Cons NC. THE PREVALENCE AND CHARACTERISTICS OF MALOCCLUSION AMONG SENIOR HIGH SCHOOL STUDENTS IN UPSTATE NEW YORK. Am J Orthod. 1965;51:437-45. 20. Crawford TP. A multiple regression analysis of patient cooperation during orthodontic treatment. Am J Orthod. 1974;65:436- 437. 21. Nanda RS and Kierl MJ. Prediction of cooperation in orthodontic treatment. Am J Orthod Dentofacial Orthop. 1992;102:15-21. 22. Miles R. Extra-oral force in orthodontics. 1963. 23. Cucalon A, 3rd and Smith RJ. Relationship between compliance by adolescent orthodontic patients and performance on psychological tests. Angle Orthod. 1990;60:107-14. 24. Gray M and Anderson R. A study of young people's perceptions of their orthodontic need and their experience of orthodontic services. Prim Dent J. 1998;5:87-93. J. Bagh. Coll. Dent. Vol. 34, No. 1. 2022 Abdulhussein and Aksoy 23 25. Haas AJ. Headgear therapy: The most efficient way to distalize molars. Semin Orthod. 2000;6:79-90. 26. Tedesco LA, Albino JE and Cunat JJ. Reliability and validity of the orthodontic locus of control scale. Am J Orthod. 1985;88:396- 401. 27. Albino JE. Development of Methodologies for Behavioral Measurement Related to Malocclusion: National Institute of Dental Research; 1981. 28. Slakter MJ, Albino JE, Fox RN and Lewis EA. Reliability and stability of the orthodontic patient cooperation scale. Am J Orthod. 1980;78:559-563. 29. Graber L. Psychological aspects of malocclusion. J CDS review. 1975;68:12-15. 30. Sergl HG and Zentner A. Predicting patient compliance in orthodontic treatment. Semin Orthod. 2000;6:231-236. 31. Burns MH. Use of a personality rating scale in identifying cooperative and noncooperative orthodontic patients. Am J Orthod. 1970;57:418. 32. Howells DJ and Shaw WC. The validity and reliability of ratings of dental and facial attractiveness for epidemiologic use. Am J Orthod. 1985;88:402-8. 33. Işık F, Sayınsu K, Trakyalı G and Arun T. Hastanın psikolojik durumunun ya da kişilik özelliklerinin ortodontik tedavi başarısı üzerine etkileri. Türk Ortodonti Derg. 2004;17:347-353. 34. Sahm G, Bartsch A, Koch R and Witt E. Subjective appraisal of orthodontic practices. An investigation into perceived practice characteristics associated with patient and parent treatment satisfaction. Eur J Orthod. 1991;13:15-21. 35. Sergl HG, Klages U and Zentner A. Pain and discomfort during orthodontic treatment: causative factors and effects on compliance. Am J Orthod Dentofacial Orthop. 1998;114:684-91. 36. Albino JE, Lawrence SD and Tedesco LA. Psychological and social effects of orthodontic treatment. J Behav Med. 1994;17:81- 98. 37. Buchanan IB, Downing A and Stirrups DR. A comparison of the Index of Orthodontic Treatment Need applied clinically and to diagnostic records. Br J Orthod. 1994;21:185-8. 38. Kerosuo H, Abdulkarim E and Kerosuo E. Subjective need and orthodontic treatment experience in a Middle East country providing free orthodontic services: a questionnaire survey. Angle Orthod. 2002;72:565-70. 39. Richter DD, Nanda RS, Sinha PK, Smith DW and Currier GF. Effect of behavior modification on patient compliance in orthodontics. Angle Orthod. 1998;68:123-32. 40. Verda C K. Ortodontik Tedavide Hasta Kooperasyonun Öngörülmesi: Maloklüzyon Algılanması ile İlişkisi,. Ortodonti Anabilim Dalı , Sağlık Bilimleri Enstitüsü,. 2006;DoktoraTezi. 41. Tuominen ML, Tuominen R and Nyström M. Subjective orthodontic treatment need and perceived dental appearance among young Finnish adults with and without previous orthodontic treatment. Community Dent Health. 1994;11:29-33. 42. Gravely JF. A study of need and demand for orthodontic treatment in two contrasting National Health Service regions. Br J Orthod. 1990;17:287-292. 43. Ali İ K. Ortodontik Tedavi gören hastalarda headgear ve ağız içi elastik kullanımnın hasta koperasyonu üzereine etkisi. . Türk Ortodonti Dergisi 2002;15 108-15. األسنان امتثال المرضى الذين يعانون من سوء اإلطباق من الدرجة الثالثة لعالج تقويم العنوان: 1اليف اكسوي, 1زيد عالء عبد الحسين الباحثون: المستخلص: الهدف ان في العالج. ا ال يزال مهم العاملهذا على الرغم من أن طرق العالج الجديدة التي تم تطويرها في السنوات األخيرة تهدف إلى تقليل الحاجة إلى تعاون المرضى ؛ ومع ذلك ، فإن الخلفية: . تقييم تعاون المرضى في عالج تقويم األسنان في اإلطباق من الدرجة الثالثة.ل كان الدراسة هذه من م عالجهم بثالثة أنواع مختلفة اتبعت هذه الدراسة أسلوب المقطع العرضي. كان السكان المستهدفون هم المرضى الذين يعانون من سوء اإلطباق من الدرجة الثالثة والذين تالمواد وطرق العمل: استبيان إلى المريض ووالدي المريض وأخصائي تقويم األسنان. من أجهزة تقويم العظام. بعد الحصول على موافقة موقعة من الوصي على كل مريض ، تم تسليم J. Bagh. Coll. Dent. Vol. 34, No. 1. 2022 Abdulhussein and Aksoy 24 )شركة آي بي إم ، شيكاغو ، إلينوي ، الواليات المتحدة األمريكية(. تم عرض المقاييس الوصفية باستخدام الجداول SPSS 20.0تم إجراء التحليالت اإلحصائية للدراسة باستخدام برنامج النتائج: ( 96٪ ؛ العدد = 52.46مريض ا لتقويم األسنان. كان أكثر من نصف المشاركين بقليل من الفتيات ) 183الدراسة شملت. والمعدل الحسابي واالنحراف المعياريمئوية( حسب التكرار )النسبة ال ٪.18.1 أكثر بقليل من FM + RME كان ما بين %CC (31.1)يليه ؛ FM (50.8%)(. أعلى معدل في مجموعات نوع الجهاز كان87٪ ؛ العدد = 47.54والباقي من الذكور ) باإلناث ، من وجهة نظر مالتقويمي عند مقارنته تظهر النتيجة التي تم الحصول عليها من الدراسة أن الذكور الذين شاركوا في الدراسة لديهم إمكانية أكبر إلظهار التعاون أثناء العالجاالستنتاج: لتعاون المريض. بالعوامل المحددة سريرية ، يمكن أن تكون هذه الدراسات مفيدة من حيث التنبؤ