{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,6,4]],"date-time":"2026-06-04T13:10:36Z","timestamp":1780578636533,"version":"3.54.1"},"reference-count":35,"publisher":"MDPI AG","issue":"6","license":[{"start":{"date-parts":[[2026,6,4]],"date-time":"2026-06-04T00:00:00Z","timestamp":1780531200000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["Dentistry Journal"],"abstract":"<jats:p>Background\/Objectives: Systematic assessment of orthodontic treatment needs is essential for prioritizing care in public health programs. The Dental Aesthetic Index (DAI) provides a composite severity score; however, understanding which individual occlusal traits drive severe treatment needs has a practical screening value. This study aimed to determine which occlusal features, categorized using established clinical thresholds, independently associated with severe orthodontic treatment need. Methods: Pretreatment records of 292 patients (141 men, 151 women; aged 13\u201342 years) were analyzed. The outcome was severe treatment need (DAI \u2265 31). Ten DAI components were categorized using IOTN-DHC severity cutpoints; Angle and skeletal classifications were also assessed. Candidate predictors (p &lt; 0.20) were entered into multivariate logistic regression with backward elimination. Discrimination was assessed by ROC analysis; internal validation used bootstrap resampling and cross-validation. Results: Of the 292 patients, 141 (48.3%) had severe treatment needs. Six occlusal features were independently associated with severe treatment need (all p &lt; 0.001): overjet severity (adjusted odds ratio [OR] = 412.4; 95% confidence interval [CI]: 82.1\u20132072.1), missing anterior teeth (OR = 29.3; 95% CI: 8.6\u201399.5), open bite severity (OR = 13.4; 95% CI: 4.6\u201339.5), diastema (OR = 7.4; 95% CI: 2.4\u201322.5), molar cusp relationship (OR = 4.7; 95% CI: 2.3\u20139.5), and anterior spacing (OR = 2.9; 95% CI: 1.5\u20135.4). The area under the ROC curve was 0.971 (optimism-corrected: 0.968), and 90.8% of the patients were correctly classified by the final model (sensitivity, 89.4%; specificity, 92.1%). Angle classification, skeletal classification, sex, age, and crowding were not included in the final model. Conclusions: Six clinically categorized occlusal features assessed by visual inspection were independently associated with severe orthodontic treatment need in this explanatory analysis, with overjet severity as the dominant determinant. Categorical severity grades based on established clinical thresholds retained strong discriminative information (optimism-corrected AUC = 0.968), suggesting that simplified assessments may be sufficient for the initial screening. Dental and skeletal classifications did not provide an independent predictive value beyond that of occlusal features. External validation is needed before clinical implementation.<\/jats:p>","DOI":"10.3390\/dj14060342","type":"journal-article","created":{"date-parts":[[2026,6,4]],"date-time":"2026-06-04T11:52:30Z","timestamp":1780573950000},"page":"342","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["Determinants of Severe Orthodontic Treatment Need Using Clinically Categorized Occlusal Features"],"prefix":"10.3390","volume":"14","author":[{"given":"Anwar S.","family":"Alhazmi","sequence":"first","affiliation":[{"name":"Department of Preventive Dental Sciences, College of Dentistry, Jazan University, Jazan\u00a0828172, Saudi Arabia"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2026,6,4]]},"reference":[{"key":"ref_1","first-page":"97","article-title":"Prevalence of malocclusion and orthodontic treatment need in the United States: Estimates from the NHANES III survey","volume":"13","author":"Proffit","year":"1998","journal-title":"Int. J. Adult Orthod. Orthognath. Surg."},{"key":"ref_2","doi-asserted-by":"crossref","unstructured":"Gudipaneni, R.K., Aldahmeshi, R.F., Patil, S.R., and Alam, M.K. (2018). The prevalence of malocclusion and the need for orthodontic treatment among adolescents in the northern border region of Saudi Arabia: An epidemiological study. BMC Oral Health, 18.","DOI":"10.1186\/s12903-018-0476-8"},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"10","DOI":"10.4103\/jos.JOS_104_18","article-title":"The prevalence of malocclusion and orthodontic treatment need of school children in Northern Saudi Arabia","volume":"8","author":"Alajlan","year":"2019","journal-title":"J. Orthod. Sci."},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"253","DOI":"10.1111\/j.1600-0528.1990.tb00070.x","article-title":"Prevalence of malocclusion and need for orthodontic treatment in Saudi Arabia","volume":"18","author":"Wisth","year":"1990","journal-title":"Community Dent. Oral Epidemiol."},{"key":"ref_5","doi-asserted-by":"crossref","unstructured":"Mtaya, M., Astr\u00f6m, A.N., and Brudvik, P. (2008). Malocclusion, psycho-social impacts and treatment need: A cross-sectional study of Tanzanian primary school-children. BMC Oral Health, 8.","DOI":"10.1186\/1472-6831-8-14"},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"512","DOI":"10.2319\/062012-509.1","article-title":"Malocclusion impacts adolescents\u2019 oral health-related quality of life","volume":"83","author":"Scapini","year":"2013","journal-title":"Angle Orthod."},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"132","DOI":"10.1016\/j.pio.2011.06.001","article-title":"An insight into four orthodontic treatment need indices","volume":"12","year":"2011","journal-title":"Prog. Orthod."},{"key":"ref_8","unstructured":"World Health Organization (1997). Oral Health Surveys: Basic Methods, WHO. [4th ed.]."},{"key":"ref_9","unstructured":"Cons, N.C., Jenny, J., and Kohout, F.J. (1986). DAI: The Dental Aesthetic Index, College of Dentistry, University of Iowa."},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"43","DOI":"10.1111\/j.1834-7819.1996.tb05654.x","article-title":"Establishing malocclusion severity levels on the Dental Aesthetic Index (DAI) scale","volume":"41","author":"Jenny","year":"1996","journal-title":"Aust. Dent. J."},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"309","DOI":"10.1093\/oxfordjournals.ejo.a035999","article-title":"The development of an index of orthodontic treatment priority","volume":"11","author":"Brook","year":"1989","journal-title":"Eur. J. Orthod."},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"240","DOI":"10.1067\/mod.2001.116401","article-title":"A comparison of the reliability and validity of 3 occlusal indexes of orthodontic treatment need","volume":"120","author":"Beglin","year":"2001","journal-title":"Am. J. Orthod. Dentofac. Orthop."},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"668","DOI":"10.1016\/j.ajodo.2019.09.009","article-title":"How is orthodontic treatment need associated with perceived esthetic impact of malocclusion in adolescents?","volume":"158","author":"Custodio","year":"2020","journal-title":"Am. J. Orthod. Dentofac. Orthop."},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"e252","DOI":"10.1016\/j.ajodo.2022.08.011","article-title":"Impact of Dental Aesthetic Index characteristics on the severity levels of malocclusion in a non-White population","volume":"162","author":"Silva","year":"2022","journal-title":"Am. J. Orthod. Dentofac. Orthop."},{"key":"ref_15","doi-asserted-by":"crossref","first-page":"496","DOI":"10.2319\/062320-576.1","article-title":"Is the adolescent\u2019s esthetic concern associated with anterior occlusal conditions or the malocclusion severity level?","volume":"91","author":"Vedovello","year":"2021","journal-title":"Angle Orthod."},{"key":"ref_16","first-page":"e75088","article-title":"Orthodontic treatment need and its relation to gender, oral hygiene, and age range in a Mexican population","volume":"16","year":"2024","journal-title":"Cureus"},{"key":"ref_17","doi-asserted-by":"crossref","first-page":"1167","DOI":"10.5005\/jp-journals-10024-3193","article-title":"Assessment of severity of malocclusion and orthodontic treatment need using the Dental Aesthetic Index and Angle\u2019s classification: A retrospective study","volume":"22","author":"Alhazmi","year":"2021","journal-title":"J. Contemp. Dent. Pract."},{"key":"ref_18","doi-asserted-by":"crossref","first-page":"55","DOI":"10.7326\/M14-0697","article-title":"Transparent Reporting of a multivariable prediction model for Individual Prognosis Or Diagnosis (TRIPOD): The TRIPOD Statement","volume":"162","author":"Collins","year":"2015","journal-title":"Ann. Intern. Med."},{"key":"ref_19","doi-asserted-by":"crossref","first-page":"W1","DOI":"10.7326\/M14-0698","article-title":"Transparent Reporting of a multivariable prediction model for Individual Prognosis or Diagnosis (TRIPOD): Explanation and Elaboration","volume":"162","author":"Moons","year":"2015","journal-title":"Ann. Intern. Med."},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"1373","DOI":"10.1016\/S0895-4356(96)00236-3","article-title":"A simulation study of the number of events per variable in logistic regression analysis","volume":"49","author":"Peduzzi","year":"1996","journal-title":"J. Clin. Epidemiol."},{"key":"ref_21","doi-asserted-by":"crossref","first-page":"155","DOI":"10.1016\/j.jcm.2016.02.012","article-title":"A guideline of selecting and reporting intraclass correlation coefficients for reliability research","volume":"15","author":"Koo","year":"2016","journal-title":"J. Chiropr. Med."},{"key":"ref_22","doi-asserted-by":"crossref","first-page":"159","DOI":"10.2307\/2529310","article-title":"The measurement of observer agreement for categorical data","volume":"33","author":"Landis","year":"1977","journal-title":"Biometrics"},{"key":"ref_23","doi-asserted-by":"crossref","unstructured":"Hosmer, D.W., and Lemeshow, S. (2000). Applied Logistic Regression, Wiley. [2nd ed.].","DOI":"10.1002\/0471722146"},{"key":"ref_24","doi-asserted-by":"crossref","first-page":"837","DOI":"10.2307\/2531595","article-title":"Comparing the areas under two or more correlated receiver operating characteristic curves: A nonparametric approach","volume":"44","author":"DeLong","year":"1988","journal-title":"Biometrics"},{"key":"ref_25","doi-asserted-by":"crossref","unstructured":"Steyerberg, E.W. (2019). Clinical Prediction Models: A Practical Approach to Development, Validation, and Updating, Springer. [2nd ed.].","DOI":"10.1007\/978-3-030-16399-0"},{"key":"ref_26","doi-asserted-by":"crossref","first-page":"27","DOI":"10.1093\/biomet\/80.1.27","article-title":"Bias reduction of maximum likelihood estimates","volume":"80","author":"Firth","year":"1993","journal-title":"Biometrika"},{"key":"ref_27","doi-asserted-by":"crossref","first-page":"564","DOI":"10.2319\/090219-571.1","article-title":"Impact of anterior occlusal conditions in the mixed dentition on oral health-related quality-of-life item levels","volume":"90","author":"Vedovello","year":"2020","journal-title":"Angle Orthod."},{"key":"ref_28","doi-asserted-by":"crossref","first-page":"986","DOI":"10.2319\/101714-743.1","article-title":"Impact of malocclusion on oral health-related quality of life in young adults","volume":"85","author":"Chen","year":"2015","journal-title":"Angle Orthod."},{"key":"ref_29","doi-asserted-by":"crossref","first-page":"403","DOI":"10.2319\/031911-195.1","article-title":"The impact of malocclusion on adolescents\u2019 dissatisfaction with dental appearance and oral functions","volume":"82","author":"Tessarollo","year":"2012","journal-title":"Angle Orthod."},{"key":"ref_30","doi-asserted-by":"crossref","first-page":"4084","DOI":"10.1038\/s41598-024-54381-6","article-title":"An epidemiological study on early orthodontic treatment need among eastern Saudi Arabian children in the mixed dentition stage","volume":"14","author":"Madiraju","year":"2024","journal-title":"Sci. Rep."},{"key":"ref_31","doi-asserted-by":"crossref","unstructured":"Sato, H., Shimpo, Y., Sekiya, T., Rikitake, H., Seki, M., Wada, S., Nomura, Y., and Tomonari, H. (2025). Correlation Between Dental Health and Aesthetic Components of Malocclusion in Junior High and High School Students: An Epidemiological Study Using Item Response Theory. J. Clin. Med., 14.","DOI":"10.3390\/jcm14134802"},{"key":"ref_32","doi-asserted-by":"crossref","first-page":"822","DOI":"10.15537\/smj.2018.8.22337","article-title":"Orthodontic treatment needs in Saudi young adults and manpower requirements","volume":"39","author":"Taibah","year":"2018","journal-title":"Saudi Med. J."},{"key":"ref_33","doi-asserted-by":"crossref","unstructured":"Stetzel, L., Foucher, F., Jang, S.J., Wu, T.-H., Fields, H., Schumacher, F., Richmond, S., and Ko, C.-C. (2024). Artificial Intelligence for Predicting the Aesthetic Component of the Index of Orthodontic Treatment Need. Bioengineering, 11.","DOI":"10.3390\/bioengineering11090861"},{"key":"ref_34","doi-asserted-by":"crossref","first-page":"2685437","DOI":"10.1155\/2019\/2685437","article-title":"Orthodontic treatment need and the psychosocial impact of malocclusion in 12-year-old Hong Kong children","volume":"2019","author":"Baram","year":"2019","journal-title":"Sci. World J."},{"key":"ref_35","doi-asserted-by":"crossref","first-page":"143","DOI":"10.1016\/j.ajodo.2016.06.028","article-title":"Influence of quality of life, self-perception, and self-esteem on orthodontic treatment need","volume":"151","author":"Meneghim","year":"2017","journal-title":"Am. J. Orthod. Dentofac. Orthop."}],"container-title":["Dentistry Journal"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/2304-6767\/14\/6\/342\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,6,4]],"date-time":"2026-06-04T12:39:05Z","timestamp":1780576745000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/2304-6767\/14\/6\/342"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,6,4]]},"references-count":35,"journal-issue":{"issue":"6","published-online":{"date-parts":[[2026,6]]}},"alternative-id":["dj14060342"],"URL":"https:\/\/doi.org\/10.3390\/dj14060342","relation":{},"ISSN":["2304-6767"],"issn-type":[{"value":"2304-6767","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,6,4]]}}}