Abstract
The aim of this longitudinal study was to assess and compare the oral health-related quality of life (OHRQoL) of patients with class II and III deformities during and after orthodontic–surgical treatment. Thirty class III and 28 class II patients were evaluated at baseline (T0), just prior to surgery (T1), at 6 months after surgery (T2), and at 12 months after debonding (T3). OHRQoL was assessed using the Oral Health Impact Profile (OHIP-14). Friedman two-way analysis of variance and the Wilcoxon signed-rank test were performed to compare the relative changes in OHRQoL during treatment. Significant changes in the overall OHIP-14 scores were observed during and after orthodontic–surgical treatment in both groups. During the pre-surgical stage, psychological discomfort and psychological disability decreased in class III patients, and class II patients experienced a significant deterioration in psychological discomfort during the same period. Six months after surgery, patients in both groups showed improvements in psychological discomfort, social disability, and handicap. Physical disability and functional limitation showed further improvement at 12 months after debonding in class II patients. This study reaffirms that orthodontic–surgical treatment has a significant effect on the OHRQoL of class III and class II patients.
Previous studies have indicated that patients hope to improve their oral health-related quality of life (OHRQoL) by undergoing orthodontic–surgical treatment. The results of many studies have shown that the primary motivation for the correction of dentofacial deformity is to improve facial aesthetics. On the other hand, some studies have reported that certain patients prefer to improve bite function rather than aesthetics. Several studies have described the psychological advantages of orthodontic–surgical treatment. These include changes in personality, improvements in self-esteem, and positive changes in lifestyle, such as improvements in personal relationships.
The evaluation of OHRQoL during orthodontic–surgical treatment helps clinicians to understand what patients have to endure during treatment and to consider this when recommending treatment options. Many studies have shown a correlation between objective orthodontic indices and patient perceptions of their own appearance and oral health condition. OHRQoL is a multifactorial index and is thus difficult to measure objectively. Tools for the measurement of OHRQoL should be selected based on the physical, social, and psychological domains. Condition-specific and generic measures have been used to evaluate the impact of orthodontic–surgical treatment on patient OHRQoL. Lee et al. reported that generic health questionnaires like the short-form of the 36-item health survey (SF-36) are not sensitive to the changes in OHRQoL and are not helpful in detecting differences in OHRQoL between individuals with and without dentofacial deformity.
Condition-specific measures can be helpful in evaluating disease-related attributes and are more sensitive to small but clinically important changes. One of these disease-specific measures is the Oral Health Impact Profile (OHIP). Slade and Spencer introduced the original 49-item OHIP based on Locker’s conceptual model, derived from the World Health Organization International Classification of Impairments, Disabilities, and Handicaps. Today, the short form of OHIP (OHIP-14) is used widely and can be employed in order to measure dysfunction, discomfort, and disability related to oral conditions. The validity of the Persian version of the OHIP-14 was reported by Ravaghi et al. Some longitudinal studies have assessed the effects of orthodontic–surgical treatment on patient OHRQoL using SF-36 and OHIP-14.
Although, the negative impacts of malocclusion might not be related to its severity, the negative impacts of deformity seem to be related to the type of malocclusion. There appear to be no reported studies that have examined the effects of the type of deformity or Angle classification of malocclusion on OHRQoL using OHIP-14. The aim of this longitudinal study was to compare changes in OHRQoL in young adults with class II and III deformities undergoing bimaxillary osteotomies for the correction of skeletal deformities using OHIP-14 at four time points: prior to treatment, just before surgery, post-surgery, and after debonding.
Materials and methods
Fifty-eight patients participated in this prospective longitudinal study (28 class II and 30 class III patients). Ethical approval for the study was granted by the relevant ethics committee. Patients with −4 mm or more reverse overjet were categorized as class III and those with +10 mm or more overjet were categorized as class II. Inclusion criteria were the following: the patient received orthodontic treatment prior to surgery via the same technique (standard edge-wise, 022 slot brackets); the patient was scheduled for a combination of a standard one-piece Le Fort I osteotomy and bilateral sagittal split ramus osteotomy (BSSRO) with rigid fixation; condylar positioning devices were not to be applied; an inter-occlusal splint was scheduled to be used for 2 weeks. Exclusion criteria were the presence of craniofacial syndromes, cleft lip/palate, and having been scheduled to receive any of the following treatments: distraction osteogenesis therapy, genioplasty, or maxillary impaction. Patients who had a postoperative infection, malunion with poor occlusion, or a nerve injury were also excluded.
OHRQoL was evaluated at four time points: prior to treatment (T0), just before surgery (T1), at 6 months after surgery (T2), and at 12 months after debonding (T3). The initial evaluation (T0) was carried out when the patient was referred to the orthodontic department, before any treatment was received. In the pre-surgical stage (T1), patients were examined just before surgery (within an average period of 0.9 years (standard deviation 0.5 years) after their treatment had been started). In the post-surgical stage (T2), patients were examined at least 6 months after surgery in order to minimize the effects of post-surgical complications (oedema, swelling, and pain) on the results. In the post-treatment stage (T3), patients were evaluated 12 months after removal of the orthodontic appliances.
To evaluate OHRQoL, the Persian version of the OHIP-14 questionnaire, which also included items related to the socio-demographic status of the participants, was used. OHIP-14 includes seven domains (two items per domain): functional limitation, physical pain, psychological discomfort, physical disability, psychological disability, social disability, and handicap. The questionnaire is designed based on a five-point scale, as follows: never (0), hardly ever (1), occasionally (2), fairly often (3), and very often (4). Each domain score can range from 0 to 8 and can be calculated by summating the responses to the items within a domain. The overall OHIP-14 score has a range of 0 to 56, where 0 indicates the best OHRQoL and 56 indicates the worst impact of oral condition on OHRQoL. Before answering the questionnaire, an orthodontist provided the patient with some information about the study and instructions on how to complete the questionnaire and helped the participant if they had questions. Participants were asked to answer all 14 questions in 30 min in a quiet classroom.
Statistical analysis
The Kolmogorov–Smirnov normality test was performed to determine if the samples conformed to a normal distribution. Friedman two-way analysis of variance (ANOVA) was employed to compare changes in OHIP-14 scores at T0, T1, T2, and T3 in each group. The Wilcoxon signed-rank test was used to compare changes in OHRQoL between the time points T0, T1, T2, and T3. The Wilcoxon signed-rank test was also used to identify the direction and amount of change during the treatment stages by comparing the level of OHRQoL at T0, T1, T2, and T3 in each group. A two-tailed Student t -test was used to compare the means of variables between class II and class III patients at the four predefined time points (T0, T1, T2, and T3).
The magnitude of the statistical difference was assessed by calculating effect sizes. The effect size was calculated by dividing the mean change by the standard deviation; the larger the effect size, the greater the magnitude of the change as a result of treatment. An effect size of <0.2 was considered minimal, of 0.2–0.49 as small, of 0.5–0.8 as moderate, and of >0.8 as large. The level of significance was set at P < 0.05; a high level of significance was indicated by P < 0.001.
Results
Of the 75 adult patients who took part in the study, 28 class II and 30 class III patients completed the OHIP-14 questionnaire at all four time points and were eligible for analysis following the application of the inclusion and exclusion criteria. Patients in the class III malocclusion group (mean age 21.3 ± 2.7 years) were significantly younger than the patients in the class II group (mean age 25.1 ± 3.4 years) ( P = 0.04). However, there was no significant difference between the two groups regarding the sex of the participants ( P = 0.543) or their educational level ( P = 0.763). Patient demographic data are given in Table 1 . Sex and educational level had no significant effect on the results of the study. Changes in the OHIP domain scores during orthodontic–surgical treatment in class II and class III patients can be seen in Tables 2 and 3 , respectively.
| Class II, n (%) | Class III, n (%) | |
|---|---|---|
| Sex | ||
| Female | 16 (57.1) | 11 (36.7) |
| Male | 12 (42.9) | 19 (63.3) |
| Education | ||
| Primary/secondary | 17 (60.7) | 16 (53.3) |
| Tertiary/university | 11 (39.3) | 14 (46.7) |
| Age, years, mean ± SD | 25.1 ± 3.4 | 21.3 ± 2.7 |
| OHIP-14 domain | T0 | T1 | T2 | T3 | P -value | ||||
|---|---|---|---|---|---|---|---|---|---|
| Mean | SD | Mean | SD | Mean | SD | Mean | SD | ||
| Functional limitation | 1.82 | 1.25 | 2.61 | 1.16 | 0.87 | 1.01 | 0.85 | 0.82 | 0.014 a |
| Physical pain | 2.86 | 1.18 | 3.57 | 1.07 | 1.61 | 1.07 | 1.11 | 0.95 | <0.001 b |
| Psychological discomfort | 3.07 | 2.09 | 3.81 | 1.24 | 1.07 | 0.82 | 1.18 | 1.02 | <0.001 b |
| Physical disability | 3.15 | 1.79 | 3.75 | 1.07 | 1.46 | 1.10 | 0.86 | 0.71 | 0.007 b |
| Psychological disability | 2.75 | 1.51 | 3.85 | 1.17 | 1.24 | 1.51 | 0.90 | 0.89 | 0.004 b |
| Social disability | 3.07 | 1.53 | 3.00 | 1.02 | 1.25 | 0.97 | 1.04 | 0.88 | <0.001 c |
| Handicap | 2.46 | 1.35 | 2.25 | 1.23 | 1.14 | 0.65 | 0.93 | 0.72 | 0.011 a |
| Overall OHIP-14 | 19.18 | 2.97 | 22.84 | 3.40 | 8.64 | 3.21 | 6.87 | 2.11 | <0.001 c |
a Significant at the level P < 0.05 (Friedman two-way ANOVA).
| OHIP-14 domain | T0 | T1 | T2 | T3 | P -value | ||||
|---|---|---|---|---|---|---|---|---|---|
| Mean | SD | Mean | SD | Mean | SD | Mean | SD | ||
| Functional limitation | 1.53 | 0.82 | 2.13 | 1.33 | 0.80 | 0.83 | 0.81 | 0.78 | 0.005 b |
| Physical pain | 1.47 | 0.86 | 1.70 | 1.06 | 0.83 | 0.65 | 0.80 | 0.66 | 0.040 a |
| Psychological discomfort | 5.23 | 1.07 | 3.23 | 1.01 | 1.00 | 0.95 | 0.93 | 0.87 | <0.001 c |
| Physical disability | 1.30 | 0.75 | 2.07 | 1.01 | 0.80 | 0.71 | 0.77 | 0.75 | 0.020 a |
| Psychological disability | 4.33 | 0.88 | 3.63 | 0.96 | 1.01 | 0.88 | 0.97 | 1.03 | <0.001 c |
| Social disability | 3.03 | 1.13 | 2.50 | 1.48 | 1.07 | 0.83 | 0.93 | 0.74 | <0.001 c |
| Handicap | 2.97 | 1.07 | 2.37 | 0.75 | 1.20 | 0.81 | 1.03 | 0.85 | <0.001 c |
| Overall OHIP-14 | 19.86 | 2.57 | 17.63 | 3.83 | 6.71 | 2.45 | 6.24 | 2.66 | <0.001 c |
a Significant at the level P < 0.05 (Friedman two-way ANOVA).
Changes in the functional limitation score
A significant increase in the functional limitation score, indicating a worsening, was observed during T0–T1 in class II patients ( Table 4 ) and a significant decrease was found during T0–T2 in class II patients and during T0–T2 and T0–T3 in class III patients ( Table 5 ). There was also a highly significant decrease during T0–T3 in class II patients. Changes in the mean OHRQoL in class II and class III patients are shown in Fig. 1 .
| OHIP-14 domain | T0–T1 | T0–T2 | T0–T3 | T2–T3 | ||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Mean | SD | P -value | Effect size | Mean | SD | P -value | Effect size | Mean | SD | P -value | Effect size | Mean | SD | P -value | Effect size | |
| Functional limitation | +0.78 | 1.75 | 0.024 a | 0.45 | −0.96 | 1.50 | 0.004 b | 0.64 | −0.97 | 1.25 | <0.001 c | 0.8 | −0.02 | 0.98 | 0.808 | 0.40 |
| Physical pain | +0.91 | 1.86 | 0.050 | 0.39 | −1.25 | 1.65 | 0.001 b | 0.75 | −2.04 | 1.75 | <0.001 c | 1.17 | −0.50 | 1.17 | 0.003 b | 0.67 |
| Psychological discomfort | +0.64 | 2.47 | 0.182 | 0.26 | −2.00 | 2.24 | <0.001 c | 0.89 | −1.89 | 2.11 | <0.001 c | 0.90 | +0.11 | 1.47 | 0.853 | 0.07 |
| Physical disability | +0.86 | 2.21 | 0.044 a | 0.31 | −1.43 | 2.10 | 0.002 b | 0.68 | −2.04 | 1.89 | <0.001 c | 1.08 | −0.61 | 1.37 | 0.028 a | 0.45 |
| Psychological disability | +1.10 | 1.87 | 0.010 a | 0.53 | −1.51 | 2.50 | 0.001 b | 0.64 | −1.85 | 1.61 | <0.001 c | 1.13 | −0.34 | 1.69 | 0.631 | 0.12 |
| Social disability | +0.07 | 1.90 | 0.828 | 0.03 | −1.83 | 1.66 | <0.001 c | 1.10 | −2.04 | 1.80 | <0.001 c | 1.13 | −0.21 | 1.17 | 0.365 | 0.18 |
| Handicap | +0.21 | 1.34 | 0.384 | 0.17 | −1.32 | 1.44 | <0.001 c | 0.91 | −1.54 | 1.35 | <0.001 c | 1.14 | −0.21 | 0.83 | 0.175 | 0.25 |
| Overall OHIP-14 | +3.71 | 4.32 | 0.002 b | 0.86 | −10.40 | 6.43 | <0.001 c | 1.62 | −12.36 | 5.57 | <0.001 c | 2.21 | −1.99 | 3.99 | 0.942 | 0.49 |
a Significant at the level P < 0.05 (Wilcoxon signed-rank test).
| OHIP-14 domains | T0–T1 | T0–T2 | T0–T3 | T2–T3 | ||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Mean | SD | P -value | Effect size | Mean | SD | P -value | Effect size | Mean | SD | P -value | Effect size | Mean | SD | P -value | Effect size | |
| Functional limitation | +0.60 | 1.52 | 0.044 | 0.39 | −0.73 | 1.21 | 0.005 b | 0.05 | −0.80 | 1.21 | 0.002 b | 0.66 | 0.01 | 1.06 | 0.960 | 0.09 |
| Physical pain | +0.23 | 1.41 | 0.435 | 0.16 | −0.63 | 1.16 | 0.011 a | 0.54 | −0.67 | 0.96 | 0.001 b | 0.69 | 0.03 | 0.85 | 0.855 | 0.03 |
| Psychological discomfort | −2.00 | 1.51 | <0.001 c | 1.32 | −4.23 | 3.45 | <0.001 c | 1.22 | −4.30 | 3.37 | <0.001 c | 1.27 | 0.07 | 1.26 | 0.668 | 0.05 |
| Physical disability | +0.77 | 1.48 | 0.013 a | 0.52 | −0.50 | 0.97 | 0.010 a | 0.51 | −0.53 | 1.14 | 0.013 a | 0.46 | 0.03 | 0.56 | 0.739 | 0.05 |
| Psychological disability | −0.70 | 1.37 | 0.014 a | 0.51 | −3.32 | 2.85 | <0.001 c | 1.13 | −3.36 | 2.98 | <0.001 c | 1.15 | 0.20 | 1.27 | 0.950 | 0.16 |
| Social disability | −0.53 | 1.90 | 0.121 | 0.27 | −1.97 | 1.80 | <0.001 c | 1.06 | −2.10 | 1.44 | <0.001 c | 1.46 | 0.13 | 1.01 | 0.572 | 0.13 |
| Handicap | −0.40 | 1.40 | 0.127 | 0.29 | −1.77 | 1.59 | <0.001 c | 1.11 | −1.93 | 1.28 | <0.001 c | 1.50 | 0.17 | 0.95 | 0.325 | 0.18 |
| Overall OHIP-14 | −2.03 | 4.85 | 0.029 a | 0.44 | −13.03 | 10.25 | <0.001 c | 1.27 | −13.76 | 7.87 | <0.001 c | 1.98 | 0.73 | 3.04 | 0.227 | 0.24 |
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