Personal Motivation

The individual’s personal motivation to seek the correction of a dentofacial deformity is an important factor for clinicians to consider (Figs. 7-1 through 7-5).* In 2000, Rivera and colleagues surveyed 142 patients regarding their reasons for choosing to undergo orthognathic surgery.⁸⁶ Seventy-one percent indicated facial aesthetic concerns, 47% stated functional issues, and 28% confirmed temporomandibular disorders as their reasons for seeking treatment. In 2007, Narayanan and colleagues surveyed 50 patients who sought orthognathic surgery and found that, for the majority, facial aesthetics rather than the correction of their occlusions was the primary motivating factor.⁵⁹ In 2007, Stirling and colleagues conducted a questionnaire and interview survey of individuals who had undergone orthognathic surgery. The 46 interviewed patients stated that their primary motivations generally included both “improvement of the occlusion and to gain a more normal facial appearance.”⁹⁷ More recently, Proothi, Drew, and Sachs completed a retrospective survey of 501 individuals who underwent orthognathic surgery to determine why they sought the procedures.⁸³ The survey group was 43% male and 57% female, and the individuals ranged in age from 12 to 45 years. Seventy-six percent stated that facial appearance was negatively affected by their pretreatment jaw condition, but only 15% claimed that their appearance was their primary motivation for undergoing surgical evaluation. Thirty-six percent stated that their occlusion was the primary motivating force. Interestingly, 33% admitted to having significant speech difficulties, and 15% complained of swallowing problems that resulted from their presenting jaw deformity.

All adolescents more or less struggle with issues related to self-identity, social acceptance, and physical appearance. The added factor of a dentofacial deformity with impaired head and neck function and negative effects on physical appearance—coupled with the need to make a decision for or against surgical correction—may compound these psychological issues. If the individual already has baseline depression, anxiety, poor self-confidence, or other social issues, the presence of a dentofacial deformity with the need for surgical correction is likely to exacerbate these symptoms. The extent to which an exacerbation of baseline symptoms occurs may depend on how much the lack of self-confidence and social problems relate to the dentofacial deformity.

A typical sequence of events is a pre-adolescent individual being referred by his or her general dentist to an orthodontist for the correction of a malocclusion. The orthodontist may have then attempted growth-modification techniques followed by a camouflage approach to “improve” the occlusion for a period of time that ranges from 2 to 8 years before finally “giving up” and suggesting a surgical referral. The adolescent and his or her family may also have pushed for a surgical referral in response to concerns about facial aesthetics and a lack of progress with regard to the full correction of the malocclusion by the orthodontist who initially felt that he or she could solve the problem with orthodontics alone. With today’s evidence-based thinking, knowledgeable clinicians should recognize the need for a surgical approach from the outset.

The adolescent and his or her parents’ motivation for correction may be clearly stated to the surgeon at the initial introduction, or it may be only indirectly discussed. The patients’ and their families’ perceptions of the surgical outcomes will be important to achieving a smooth recovery and a favorable outcome. The results—both functional and aesthetic—should be clearly and realistically articulated by the surgeon, openly discussed, and agreed to by all parties before proceeding.

Baseline Mental Health

Individuals who do not have sufficient preoperative psychological or emotional stability are more likely to experience depression, anxiety, or panic attacks and to demonstrate difficulty complying with treatment demands during the early postoperative phase.16,17,21,27 They will also have greater difficulty with an outcome that does not meet their preconceived and often incompletely articulated expectations. If so, after surgery, they may become easily frustrated and then angry, and this may involve a loss of confidence in the surgeon. They may break off communication and seek additional opinions to justify their concerns. Some may even resort to litigation should a perceived complication or suboptimal outcome occur. Recognizing and addressing these patient-specific tendencies before surgery is the best way to limit or mitigate problems after surgery.

After an initial screening examination, a more in-depth psychological evaluation may be beneficial.8,18,24,96 The patient and his or her family’s motivation and the patient’s readiness for surgery should also be assessed. Unless a sufficient support system is in place, the stress of the necessary convalescence is likely to worsen any premorbid conditions in the patient. An initial screening that results in red flags for potential emotional problems is best followed up with a more focused psychological evaluation. The patient’s therapist should give clearance that the individual is considered emotionally stable enough to undergo the proposed treatment. When the treating clinicians (i.e., the surgeon, the orthodontist, and the general physician) have knowledge of the patient’s premorbid tendencies, coping strategies can be instituted proactively to minimize postoperative stress. The treating mental health professional should be available to the patient, the family, and the surgical team during hospitalization, after discharge, and throughout the patient’s convalescence.

High-Risk Social Behaviors

High-risk social behaviors that would be expected to affect a successful outcome should be identified before surgery. Examples include prior dependence on alcohol or on prescription or non-prescription illegal drugs. The prevalence of these past and current behavior patterns in the general population is significant and cannot be ignored.

Baseline Eating Disorders

Clinical studies indicate that between 0.5% and 1.0% of late adolescent and young adult women meet the criteria for anorexia nervosa, and between 1% and 3% meet the criteria for bulimia nervosa.⁹² Eating disorders are multi-determined problems, and they are most commonly recognized among female adolescents. Risk factors may include a perfectionist personality type, a family history of an eating disorder, a history of trauma, a tendency toward feelings of inadequacy, and low self-esteem despite external accomplishments. Patients with eating disorders often exhibit rigid cognitive patterns that are characterized by an all-or-nothing way of thinking.

Orthognathic procedures will significantly alter the diet (i.e., liquids only) and appetite level, with an expected change in nutritional intake for at least 5 weeks. Significant weight loss during the initial 2 weeks of recovery is to be expected, even among healthy individuals. The question is raised as to whether or not these dietary and postsurgical metabolic changes will tend to exacerbate a baseline eating disorder. Maine and Goldberg completed a study to determine if an elective dental manipulation—which, by necessity, results in eating discomfort and dietary restrictions—would likely influence the recovery of or result in a relapse for an individual with a baseline eating disorder.⁵⁴ Three questions concerning dental and maxillofacial procedures were added to a standard questionnaire assessment of a consecutive series of 97 individuals who were entering an eating disorder therapy program. The additional questions were designed to determine the influence of dental and maxillofacial interventions on individuals with baseline eating disorders. All 97 study subjects complied with the questionnaire; 75 of the study patients were 25 years old or younger, and 53 were diagnosed with anorexia nervosa.

Interestingly, 9.3% of the study patients who had undergone either significant orthodontic therapy or the removal of the wisdom teeth in the past indicated that the dental procedure—which, by necessity, caused eating discomfort and diet alterations—had either exacerbated or resulted in a relapse of their baseline eating disorders. This study confirms that a history of an eating disorder should alert the orthodontist and the orthognathic surgeon to potential postoperative difficulties. With an awareness of the individual’s baseline conditions, the orthodontist, the surgeon, the primary care physician, and members of the psychosocial team may establish guidelines for postoperative behavioral and nutritional objectives to closely monitor to ensure a smooth recovery.

Social Interaction Issues

Ongoing family or social peer conflicts or greater-than-average worries expressed by the individual or his or her family regarding the surgery, the preparation for the surgery, or the anticipated recovery period are red flags.1,29,33,41 When considering the timing of surgery for the adolescent or young adult, the family should take into account the anticipated impact on the patient’s everyday school and social activities, including examination schedules, college applications and interviews, and participation in sports activities. The surgeon’s ability to provide a clear picture of the expected recovery time and the patient’s ability to return to partial and regular activities is important and will vary according to the patient’s age and stage in life (e.g., adolescent, college or graduate student, middle-aged adult with family and work commitments). Clarifying anticipated postoperative limitations in physical, cognitive, and emotional activities is important to setting the stage for a successful outcome.