Relationship of Smile Esthetics and Quality of Life Among High-School Adolescents in Al-Ahsa, Saudi Arabia: An Analytic Cross-Sectional Study

<b>Background/Objectives</b>: Adolescents may experience psychosocial consequences from minor dentofacial variations. The relationship between objectively rated smile esthetics and self-reported psychosocial impact remains under-studied in Saudi adolescents. This study aimed to investigate the relationship between the objectively measured smile esthetics with the subjectively reported psychosocial impact of perceived smile esthetics. <b>Methods</b>: Cross-sectional, multistage cluster-stratified sample technique was used to study adolescents aged 15-20 years (n = 344) from Al-Ahsa schools. Standardized extra-/intraoral photography supported Dental Esthetic Screening Index (DESI) scoring and psychosocial impact using Arabic Psychosocial Impact of Dental Aesthetics Questionnaire (PIDAQ) were applied. Reliability was assessed through two-way mixed intraclass correlation coefficient (ICC), Bland-Altman analysis, standard error of measurement (SEM), and minimal detectable change at the 95% confidence level (MDC95). Associations were examined using correlations and regression models. <b>Results</b>: The distribution of DESI categories was excellent (6.4%), good (29.7%), satisfactory (42.2%), insufficient (18.9%), and poor (2.9%). The distribution of PIDAQ impact levels was minimal (37.8%), slight (41.6%), moderate (18.0%), and significant (2.6%) (age <i>p</i> = 0.052; sex <i>p</i> = 0.417). DESI and total PIDAQ were weakly correlated (Spearman ρ = 0.248, 95% CI 0.143-0.347; <i>p</i> < 0.001). In a multivariable linear regression model with continuous PIDAQ total score as the outcome (R² = 0.525; adjusted R² = 0.516; <i>p</i> < 0.001), self-perceived smile dissatisfaction (B = 7.789; β = 0.478; <i>p</i> < 0.001) and tooth-color dissatisfaction (B = 4.099; β = 0.306; <i>p</i> < 0.001) showed the strongest associations with higher PIDAQ scores, while DESI total score showed a smaller association (B = 0.310; β = 0.120; <i>p</i> = 0.002). Age and sex were not significant predictors after adjustment. <b>Conclusions</b>: Objective smile esthetics were modestly associated with psychosocial impact, whereas adolescents' self-perceived smile and tooth-color dissatisfaction were strongly associated with worse psychosocial outcomes. Although the smile esthetics may be clinically acceptable, adolescents can still experience reduced oral health-related quality of life due to the psychosocial impact of perceived dental esthetics. These findings support incorporating brief subjective questions on smile and tooth-color perception alongside objective assessment during routine adolescent dental care.