Malocclusion is among the most prevalent oral health conditions globally, affecting approximately 56% of populations. Prevalence varies considerably across populations and diagnostic criteria. ¹ Beyond functional consequences, malocclusion carries a significant psychosocial burden, particularly during childhood—a period of increased sensitivity to peer judgments and appearance-based evaluation. ^{2– 4}

A meta-analysis of 40 cross-sectional studies demonstrated significantly reduced oral health–related quality of life (OHRQoL) in children with malocclusion. Children with malocclusion were 1.74 times more likely to experience OHRQoL impairment than unaffected peers. ⁵

Severity showed a dose-response relationship: Children with normal or mild malocclusion were 56% less likely to experience quality-of-life impairments than those with severe malocclusion. ⁶

Despite robust evidence linking malocclusion to compromised quality of life, the association between malocclusion and school bullying remains contested. A recent systematic review found that 88% of studies reported a positive correlation between dentofacial anomalies and victimization. ⁷

However, a subsequent meta-analysis yielded inconclusive results, reflecting heterogeneity across studies. ⁸

Bullying, defined as recurrent aggressive behavior within a power- imbalanced relationship, carries serious psychological and academic consequences, including reduced self-esteem, academic decline, and heightened risk of anxiety and depression. ⁹

Appearance- related bullying specifically affects 7% to 47.8% of children globally, ^{10, 11} underscoring the social significance of visible dentofacial characteristics in school settings. ¹²

The mixed dentition stage (8–12 years) represents a critical window during which peer awareness intensifies, magnifying psychosocial impacts of visible dentofacial anomalies such as anterior crossbite. ³

This sagittal malocclusion occurs in approximately 11% of populations, ¹ and can compromise facial profile perception, cause functional mandibular displacement and abnormal incisal wear, and worsen skeletal Class III patterns if untreated. ¹³

Beyond functional consequences, anterior crossbite affects dental aesthetics during speech and smiling; its psychosocial effects correlate with severity. ¹⁴ However, limited research examines the relationship between anterior crossbite severity and appearance-related bullying, especially in Middle Eastern populations. Understanding these psychosocial dimensions is important for timely orthodontic referral and early intervention.

The Risk of Malocclusion Assessment (ROMA) Index provides an objective and standardized, reproducible classification of occlusal disorders, including anterior crossbite. ¹⁵ The modified Olweus Bully/Victim Questionnaire enables systematic evaluation of bullying exposure, appearance- related victimization, severity, patterns, and contexts. ^{16, 17}

Combining objective clinical severity assessment with validated psychosocial measurement minimizes subjective bias and strengthens methodological rigor.

This study addressed a significant knowledge gap: the lack of severity-based analyses of anterior crossbite and bullying, and the absence of data from Syrian populations. The study aimed to ascertain the prevalence of anterior crossbite in children aged 8–12 years using the ROMA Index, estimate the prevalence of appearance-related bullying using the modified Olweus questionnaire, analyze the association between anterior crossbite severity and bullying exposure while controlling for age and gender, and describe bullying patterns and contexts.

The findings are expected to deepen the understanding of the psychosocial dimensions of anterior crossbite during mixed dentition, inform early orthodontic intervention decisions integrating functional and psychological considerarions and support integration of orthodontic care into school-based bullying prevention programs.

This cross-sectional analytical study received ethical approval from the Research Ethics Committee at the Faculty of Dentistry, University of Damascus (IRB No. UDDS 2614_28042025/SRC_2320) and authorization from the Ministry of Education (No. 4/443, 02/07/2025).

The study followed the Declaration of Helsinki (2013), ¹⁸ and written informed consent was obtained from parents or legal guardians of all participating children.

Data collection occurred between July and December 2025, and the research complies with the STROBE guidelines for observational studies. ¹⁹

A total of 2,080 children aged 8–12 years were included.

Among the participants, 408 children (19.6%) presented with an anterior crossbite. Of these cases, 15% required immediate intervention, 2.6% showed signs of malocclusion that could persist or worsen, and2% required routine occlusal monitoring. Findings are presented in Table 1.

The modified Olweus Bully/Victim Questionnaire identified 34.4% of the children as victims of dental appearance- related bullying. Victimization was defined in accordance with established Olweus criteria, whereby children who reported experiencing bullying two or more times per month were classified as victims. In contrast, those who reported no instances of bullying or only occasional occurrences were categorized as non-victims (see Table 2).

A significant association was observed between occlusal status and dental appearance–related bullying (χ ² = 694.38, df = 3, p < 0.001), with Cramer’s V = 0.578 (p < 0.001).

Children with anterior crossbite, particularly those with concomitant malocclusion, exhibited the highest prevalence of bullying compared to those with malocclusion alone or normal occlusion ( Table 3).

Binary logistic regression, adjusted for age and gender, confirmed these findings. Older age was significantly associated with increased bullying victimization (Exp(B) = 1.556; 95% CI: 1.240–1.953; p < 0.001), while gender was not significant (Exp(B) = 1.007; 95% CI: 0.805–1.261; p = 0.949).

Compared with children with normal occlusion, those with both malocclusion and anterior crossbite had substantially increased bullying exposure, (Exp(B) = 0.000; 95% CI: 0.000–0.003; p < 0.001).

Children with anterior crossbite alone also showed significantly higher victimization risk (Exp(B) = 0.231; 95% CI: 0.176–0.303; p < 0.001), whereas those with malocclusion only did not differ significantly from the reference group (Exp(B) = 2.162; 95% CI: 0.735–6.360; p = 0.161). Findings are presented in Table 4.

These results indicate that anterior crossbite, whether alone or combined with malocclusion, significantly increases bullying risk, whereas malocclusion without crossbite does not significantly influence victimization.

Among children with anterior crossbite, ordinal logistic regression revealed a clear dose–response relationship between ROMA severity and bullying severity.

Children requiring immediate treatment exhibited the highest bullying scores (Estimate = −3.761, 95% Confidence Interval: −4.730 to −2.793; p < 0.001), followed by those requiring observation (Estimate = −3.364, 95% Confidence Interval: −4.954 to −1.774; p < 0.001).

Children under routine follow-up showed no significant difference from the reference category (Estimate = −0.621, 95% Confidence Interval: −2.024 to 0.782; p = 0.385). Age (Estimate = 0.076; p = 0.649) and gender (Estimate = −0.477; p = 0.069) were not significantly associated with bullying severity. These findings indicate that bullying likelihood and severity are positively correlated with anterior crossbite severity and are independent of the child’s age and gender (see Table 5).

Teasing and mocking were the most common forms, reported by 97.2% of children with anterior crossbite only, 94.4% of those with both malocclusion and anterior crossbite, and 71.4% of those with malocclusion only. These differences were statistically significant (χ ² = 50.79, df = 2, p < 0.001) with a moderate strength of association (Cramer’s V = 0.291).

Unpleasant nickname- calling showed a strong association with occlusal status (χ ² = 96.38, df = 2, p < 0.001; Cramer’s V = 0.401), with prevalence varying significantly across groups. Social exclusion was less frequently reported, remained significantly correlated with occlusal status (χ ² = 969.95, df = 2, p < 0.001; Cramer’s V = 0.342). Physical bullying occurred infrequently across all groups but still showed a statistically significant difference (χ ² = 10.09, df = 2, p = 0.006; Cramer’s V = 0.130).

Bullying locations varied significantly among occlusal groups (χ ² = 13.23, df = 6, p = 0.004; Cramer’s V = 0.133).

Children with both malocclusion and anterior crossbite most frequently experienced bullying on the playground (63.0%), followed by the classroom (25.9%) and the route to school (11.1%), with no reports from.

Those with malocclusion reported incidents only at the playground (42.9%), classroom (31.4%), route to school (14.3%), and multiple locations (11.4%). Children with anterior crossbite only experienced bullying predominantly on the playground (64.0%), in the classroom (14.6%), on the route to school (16.2%), and in multiple locations (5.1%).

Children with normal occlusion were excluded from the analysis, as dental appearance-related bullying was negligible in this group. Consequently, all descriptive and comparative analyses of bullying patterns focused exclusively on children with malocclusion and/or anterior crossbite ( Table 6).

The study demonstrated that anterior crossbite extends beyond functional and aesthetic concerns to significantly impact children’s well-being in school settings. The prevalence of 19.6% in this study substantially exceeds global estimates off approximately 11% for mixed dentition, which are approximately 11%, placing this population in a higher-risk category and underscoring the urgency for early intervention. ¹

Regional prevalence varies considerably, ranging from (5.5%) in Iraq to 14% in Palestine, with Egypt and Jordan reporting 10.1% and (6.8%) respectively ^{35, 36} Jordan. ^{37, 38}

Notably, most existing studies examined older children than the current sample (ages 8–12 years), a critical developmental period characterized by ongoing dental and craniofacial changes. ³⁹

During this stage, mild cases may spontaneously resolve or benefit from early treatment, making this age group essential for accurately assessing the overall disease burden. ⁴⁰

The current study fills an important gap by providing both prevalence and severity estimates using the standardized ROMA index data previously lacking in early mixed dentition populations. These findings are vital for designing school-based screening initiatives and facilitating timely orthodontic referrals.

Dental appearance-related bullying affected 34.4% of the sample, highlighting a significant public health concern. Chronic childhood bullying exposure is well-documented to increase the risk of anxiety, depression, low self-esteem, and academic underperformance. ⁴¹

Longitudinal evidence demonstrates that bullying victims face substantially elevated odds of developing psychological disorders extending into adolescence and adulthood (Odds Ratio = 1.60; 95% Confidence Interval: 1.42–1.81). ⁴²

By linking a clinically diagnosable occlusal condition to a prevalent psychosocial stressor, this study reframes anterior crossbite as more than a localized dental issue. It is a broader health determinant affecting mental well-being and academic success.

Statistical analyses revealed a robust association between malocclusion and bullying, Cramer’s V = 0.578, representing a substantial effect size with both clinical and epidemiological relevance. This finding aligns with prior research indicating that children with prominent anterior dental characteristics experience higher bullying rates than their peers without such features. ⁴³ These results underscore the essential role of anterior facial appearance in social perception during a formative development period for identity formation and self-esteem, ⁴⁴ supporting the integration of malocclusion as a psychosocial risk marker in school health programs.

The graded association between anterior crossbite severity and bullying corresponds with Bradford Hill’s criteria for establishing causality, particularly, the epidemiological dose–response principle. ⁴⁵

Ordinal logistic regression analysis indicated that higher severity scores, particularly those necessitating immediate intervention, experienced significantly greater bullying exposure (p < 0.001). This dose- response pattern reinforces the causal inference and strengthens the importance of integrating severity assessments into school-based screening and early prevention strategies. Such targeted interventions could reduce both the clinical burden.

Age emerged as a significant predictor of bullying risk, while gender did not demonstrate a significant effect. This finding is consistent with existing studies indicating showing that bullying exposure typically increases during late primary and early adolescence. ⁴⁶

While gender differences in bullying do occur, they generally reflect variations in bullying type rather than severity. ⁴⁷ The age-related increase likely reflects a heightened sensitivity to social evaluation and physical appearance during this development stage, emphasizing the critical need for preventive interventions targeting older primary school children.

Verbal bullying, including teasing, derogatory comments, and name-calling, was substantially more prevalent than physical aggression, consistent with evidence that verbal and social forms of bullying dominate among children within this age group. ⁴⁸

Although physical bullying occurred less frequently, the data suggest that appearance-based verbal harassment can escalate into more severe forms of aggression without early intervention. This finding underscores the importance of comprehensive, multifaceted prevention strategies within schools. Schools emerged as the primary bullying setting, underscoring the critical role of both environmental and organizational factors on aggressive behaviors. Meta-analytic evidence demonstrates that increased school supervision and anti-bullying initiatives significantly reduce bullying rates. ⁴⁹

These findings support an integrated approach combining early orthodontic screening with school-based bullying prevention initiatives- a dual approach with substantial potential to improve both oral and psychosocial health outcomes.

These findings should be interpreted within the context of the study’s cross-sectional design, which limits causal inference. Additionally, unmeasured variables such as self-esteem and familial support factors may mediate the observed associations. Therefore, longitudinal, multicenter studies are needed to assess the long-term psychosocial benefits of early orthodontic intervention and to evaluate the cost-effectiveness of incorporating malocclusion screening into routine school health programs.

Anterior crossbite severity represents a clinically significant indicator with considerable social consequences. Future interventions should operate within a comprehensive public health framework that integrates oral health, psychological well-being, and educational environments.

A multi-level intervention combining early orthodontic care, school-based anti-bullying programs, and community education could significantly reduce the psychosocial burden associated with malocclusion during childhood and promote holistic child health and development.

An anterior crossbite extends beyond dental aesthetics and function. It represents a significant psychosocial stressor in school environments, with effects that intensify as severity increases. This study establishes a clear dose–response relationship between anterior crossbite severity and bullying victimization, demonstrating clinical and social relevance.

Early identification of anterior crossbite severity during mixed dentition enables timely recognition of children at increased risk for psychosocial harm. Integrating orthodontic severity assessments into school health screening programs coupled with comprehensive anti-bullying initiatives offers a dual -intervention approach to safeguard children’s mental health and academic success.

Corresponding author

Correspondence to Farah M. Babakurd